A patient is seen at your office complaining that her right eye is physiologically higher than her left eye. How would you orient a prism to help her appearance?

When addressing a patient who perceives that one eye appears higher than the other, the goal is to create an optical effect that helps align the visual axes or the perceived heights of the eyes. The correct choice involves using a base up prism over the right eye.

Prescribing base up prism over the right eye will effectively create an upward shifting effect in the position of the right eye when viewed from an external perspective. This compensatory measure helps to visually balance the two eyes, as it gives the impression that the higher eye (right eye) is lowered. By increasing the apparent height of the lower eye (left eye) or decreasing the height of the higher eye (right eye) through the prismatic effect, the discomfort regarding the perceived disparity in height can be alleviated.

In this scenario, the other options do not achieve the desired optical effect of visually equalizing the appearance of the eye levels. Each alternative either does not correct the perceived misalignment or could exacerbate the issue instead of resolving it. Thus, using a base up prism over the right eye is a strategically sound choice to help improve the patient's appearance.