All photos courtesy of Dr. Debby Feinberg
By Debby Feinberg, OD, FAAO
Sept. 15, 2026
In the early days of my work in NeuroVisual Medicine, I started to notice a trend: the magic age of 40. I was seeing so many 40-something patients.
It made sense. It’s the age where their eye muscles, that used to work so hard in maintaining alignment for them, weren’t functioning as they once were. The ability to compensate is often lost or diminished. They may start to experience more unsteadiness, and their perception is not as good.
As these changes begin to feel troubling to patients, it’s the perfect time to intervene. I like to explain to patients that as people get older, binocular vision dysfunction (BVD) becomes more prevalent.
Many people suffer from minor eye misalignments (such as vertical heterophoria) where the eyes do not work together properly as a team.1 There’s an entire curve of this, but right around 40 is where it starts to matter more and more in people’s consideration. Taking steps now can help prevent falls 20 years down the road.
If you’re serving adults in this age range, you’re already seeing the population where these issues become more common.
WHY THIS IS GOOD FOR A PRACTICE
A lot of us never really learned about dizziness and headaches in this way. When you capture these patients and provide positive outcomes, we have an opportunity to provide care in an area that is often missed in more traditional settings.
For business professionals, that means there’s opportunity in both the clinical and practice model. You can build something that serves a patient subset that is common, under-recognized and not always getting the right answer elsewhere.
The BVD Assessment helps identify opportunities to help patients, whether in your own practice or to refer to a specialist.
SCREENING IS THE GATEWAY
The eye ages, and as it does, BVD becomes something worth screening for more deliberately.
You don’t have to guess to know if a patient may have BVD. That’s the value of a screening tool like the BVD questionnaire. After 20 years of using this screening process, we validated the questionnaire. It’s now a scientific research instrument, too.
What that means practically is that the questionnaire helps sort patients. Whether they score high or low, the results still tell you something useful. The score may point towards BVD, but sometimes it may be signaling you to consider other issues, too, like postural orthostatic tachycardia syndrome, third mobile window syndrome or other inner ear problems.
All the information is valuable. Even if it’s not something you can care for directly, you’re at least heading them in the right direction towards the next step.
VALIDATING PATIENT CONCERNS
When patients fill out the questionnaire, a lot of times they have that moment of recognition that I know their secrets. The “little” things they’ve been struggling with: that they don’t like big department stores? Or that they feel clumsy, awkward or hate bright lights?
That reaction tells you something important. These patients often come in already feeling seen. They know they’re in the right office. And that can make the whole process easier, because the screening helps validate what they’ve been experiencing.
EMBRACE THE SPECIALTY CARE
NeuroVisual Medicine offers a unique pathway for doctors. The work fits certain doctors better than others. Some people love a fast pace, while others would rather know their patients better and take more time because that’s more satisfying. Our initial exams are scheduled for 80 minutes. That’s a unique fit, and not everybody is going to gravitate toward it.
When you do the work well, the word will spread. We’ve trained more than 80 doctors through our NeuroVisual Medicine Institute, yet there is still so much opportunity. I’ve had patients travel from states away and even other countries for this care.
BUILD A REFERRAL NETWORK
If you’d rather not build this specialty into your own practice, screening is still a meaningful way to help these patients. Use the BVD questionnaire to identify patients who may benefit from a NeuroVisual Evaluation, then refer them to a colleague who practices NeuroVisual Medicine. That way, patients who might otherwise be missed still get to the right care, and you stay focused on what you already do best.
A PRACTICAL TAKEAWAY
Don’t overlook 40-plus patients. This is the age where these issues become more prevalent, and it’s a population that can benefit from better screening and better sorting.
That’s where NeuroVisual Medicine has a real opportunity. It helps patients, it gives doctors a meaningful niche and it puts the practice in a position to do work that is both useful and needed.
References
1 https://vision-specialists.com/vision-health/eye-conditions/vertical-heterophoria/
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Debby Feinberg, OD, FAAO, is the founder of NeuroVisual Medicine, an optometric subspecialty dedicated to identifying and treating subtle vision misalignments that cause symptoms not typically associated with the eyes—including headaches, dizziness, anxiety, gait and balance problems, neck pain and reading or learning difficulties. Since 1995, she and her colleagues at Vision Specialists of Michigan have treated more than 30,000 patients with Binocular Vision Dysfunction and Vertical Heterophoria, achieving an average 80% reduction in symptoms within six weeks. Through the NeuroVisual Medicine Institute, she has trained more than 80 optometrists worldwide in these techniques. Her work has been presented nationally and internationally and published in peer-reviewed literature spanning traumatic brain injury, neuro-otology and optometry. To contact her: drdebby@nvminstitute.org |
