My Tricky Plastic Brain

I found a collection of school photos in an album at my mother’s house. We’ll come back to these later. 

One evening, a decade ago, I was looking down at my phone that was resting on a table below me. Suddenly I got dizzy. Very dizzy: the kind of dizzy where I had to hold onto the table to keep myself from falling over. 

The worst of it passed in a few minutes, but, give or take, I’ve had a persistent vague feeling of, well, something not being quite right ever since. Not dizziness, really. Not vertigo. But something just being off. Visual dissonance.

In the intervening ten years, I’ve sought help for understanding what’s going on. I talked to my family doctor, my optometrist, a physiotherapist specializing in vertigo, a physiotherapist specializing in concussions. 

What gradually emerged is that my eyes are misaligned. Rather than working smoothly together in a ballet of synchronized binocular vision, one eye is going off half-cocked some of the time, and everything that I have been feeling is a result, directly or indireclty, of that fact.

I found some relief from my symptoms by having my eyeglasses prescription adjusted, adding a prism, and using dedicated “computer glasses.” Then, last year, I had a pair of Neurolens eyeglasses prescribed, with a graduated prism, and they’ve made a noticeable improvement.

Despite these gains, which have helped enough to make daily life reasonable, I’ve remained curious about the underlying physiology behind my problem. Had a suffered a concussion that I somehow missed? Is it inherited? Something else? Is there anything else that can be done?

Last year, I stumbled, almost accidentially, upon the practice of orthoptics:

Orthoptists are the experts in diagnosing and treating defects in eye movements and problems with how the eyes work together, called binocular vision. 

I was excited to learn that there is an entire profession dedicated to the exact issue I was living with, and then even more excited to find out that Prince Edward Island has its very own publically funded orthoptics clinic.

Orthoptists investigate, diagnose, and treat abnormalities in eye alignment, eye movement, and binocular vision. A variety of treatments may help patients, including glasses, prisms, eye patching, eye exercises, etc.

I asked my optometrist to refer me to the clinic, in March of 2025. 

I had my appointment last week, a year later.

At that appointment, the provincial orthoptist, Mariah Hogan, spent about an hour with me, going through a series of tests and observations that bore something in common with an everyrday regular eye exam, of the sort of had dozens of times, but then extending into new territory focused on alignment, double vision, and the muscles of my eyes.

What emerged she described, in her report, as “likely congenital longstanding right cranial nerve 4 palsy.” More fully:

On full measures, his RHT increases on opposite (left) gaze and ipsilateral (right) tilt, in keeping w ith a Right CN4 palsy. As such, I also notice a marked right superior oblique underaction of -2.5, w ith corresponding right inferior oblique overaction of +3.

I have a Superior Oblique Palsy, also known as a Congenital Fourth Nerve Palsy:

Congenital fourth nerve palsy is a condition present at birth characterized by a vertical misalignment of the eyes due to a weakness or paralysis of the superior oblique muscle.

One amazing aspect of this is that I don’t experience double vision, something that affects many people with this issue. The orthoptist concluded that this was something I’ve likely lived with all my life, and that my brain has learned, essentially, how to turn off inputs from one eye when I’m looking at at distance—“suppression ability” is what she wrote. 

She went as far as to stimulate double vision in me through a series of lenses and gazes. 

Ack! 

Trust me, you don’t want double visiion. 

I don’t want double vision.

Fortunately, I don’t have it.

Because my brain is so good a supressing double vision “at the CPU level,” I’ve never known that it was doing this. And for it to have become so good means, she told me, that it was likely something my brain learned before I was 7 years old.

That I’ve only noticed residual side-effects of this palsy in my 50s isn’t unusual, and, indeed, looking at my father’s medical history, I found this:

Occasional problems with double vision started about 1995 but were not successfully resolved till 1997 when they were corrected with prisms in the glasses. Later detailed examination showed an imbalance in eye muscles which appeared to be stable. 

My father was 60 years old in 1997. 

I turn 60 next month. 

So, yes, congenital and likely inherited.

Now, pop back up and look at that collection of school photos. One of the symptoms of a superioe oblique palsy is a “characteristic head tilt” that “is usually away from the affected side to reduce eye strain and prevent double vision.” 

It’s there. In almost every photo:

I’ve never noticed this head tilt, and it’s never been pointed out to me, but I know it well, because I’ve lived with persistent neck strain that I imagine goes hand in hand with it.

After living with this so far in life, I’ll live with this for the rest of my life (there are surgical interventions possible, but not universally recommended; maybe an option for the future).

Beyond the relief I feel at having what I’ve been living with ascribed to an actual physiological condition (as opposed to say, being cursed), I’ve found the metaphor of my brain swooping in to protect me from double vision, without me even knowing this was happening, as a very helpful metaphor in my work with a therapist. 

Our brains are amazing. And plastic. And tricky.