Rethinking Dizziness The Role of Vision, Utricle, and Saccule

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Rethinking DizzinessThe Role of Vision, Utricle,
and Saccule

• Arthur Rosner, MD FACS
• Debby Feinberg, OD
• Mark Rosner, MD FACEP

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John Kemink MD, 1949-1992
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Shiro FujitaListen to the Patient
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How it Started
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Current Diagnosis

• Failure to compensate
• Non-vertiginous dizziness
• Mal debarquement syndrome
• Mall patient
• Visual vertigo
• dyslexia

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Current diagnosis

• Vestibular Migraine
• Vomiting with anesthesia
• Motion sickness
• Central vertigo
• Neck pain
• Anxiety

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Current diagnosis

• Menieres Disease
• Agoraphobia
• Bilateral vestibular loss
• Vomiting on VNG

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Prevalence

• 4 of my practice has binocular vision
  dysfunction
• Over 8000 patients have been treated
• Optometrists now trained in other states

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Vertical Heterophoria
A condition where one eye sees the image higher
than the other eye. The brain is intolerant of
the unclear image, and forces the eyes to attempt
to create a clear image. The strain on the
visual system causes symptoms that mimic
conditions such as sinusitis, inner ear disorders
and migraines.
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History

• Von Graefe. A Uber musculaire Asthenopic. Arch
  Opthal 18628314-367.
• Doble J, Rosner M, Feinberg D, Rosner A ,
  Identification of Binocular Vision Dysfunction
  (Vertical Heterophoria) in Traumatic Brain Injury
  Patients and Effects of Individualized Prismatic
  Spectacle Lenses in the Treatment of
  Postconcussive Symptoms A Retrospective
  Analysis2010 PMR 20102244-253.

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Transient Diplopia or Blurred Vision
Thierry M. Using Prism Graphics. Detroit Free
Press. August 2, 2005.
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Symptoms
Dizziness Headache Head Tilt Nausea Agoraphobia An
xiety Motion sickness Unsteady while
walking Problems reading
Thierry M. Using Prism Graphics. Detroit Free
Press. August 2, 2005.
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Anxiety Symptoms Associated with Dizziness

• The multiple objects in a large space can
  overload the visual system and trigger a dizzy
  episode. The resultant feeling is one of being
  overwhelmed and anxious.
• Overwhelmed in big box stores, malls,
  supermarkets, sports arenas, stadiums, theatres
• Anxious in crowds, school assemblies

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Trigeminal nerve
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Trigeminal nerve
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Otolaryngology Examination
Head Tilt Vertical and horizontal disparity
between the eyes Convergence insufficiency Duplica
tion of symptoms on eye movements
Thierry M. Using Prism Graphics. Detroit Free
Press. August 2, 2005.
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Study Design

• Otolaryngology examination
• Pre-treatment Vertical Heterophoria Symptom
  Questionnaire (VHSQ)
• Optometry examination
• Eyeglasses with corrected prescription including
  vertical and horizontal prism
• Post-treatment VHSQ

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Inclusion and Exclusion Criteria

• 100 patients sent for optometry evaluation
• 60 patients seen by the optometrist
• 39 patients filled out pre and post
  questionnaires
• 29 patients with vertical heterophoria treated
  with prism

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Demographics
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Chief Complaint on Presentation to the
Otolaryngologist
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Optometry Evaluation
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Trial Frame
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Trial Framing

• Dynamic process between patient and doctor
• Quarter unit prism lenses are required
• Time needed between adjustments to allow
  muscles in eyes and neck to relax
• Prescription modified based on the patients
  response
• Needs to be learned in person

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Prescription
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Statistics

• Likert scale
• 0 Never
• 1 Occasionally
• 2 Frequently
• 3 always

• Paired t-test before and after treatment
• For each question
• Total questionnaire score

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Optometric Examination

• Standard optometric exam
• Phoria testing, vertical vergence, and Maddox rod
  tests do not predict the need for prism, amount
  of prism or direction of prism

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Rank Question P Value Mean difference after treatment
1 Do you experience dizziness, light-headedness, or nausea associated with bending down then standing back up quickly from a seated position? lt .0001 .8271
2 Do you blink to clear up distant objects after working at a desk or with near centered tasks? lt .0001 .8271
3 Do you feel unsteady with walking? lt .0001 .758
4 Do you tire easy with reading? lt .0014 .724
5 Do you experience poor depth perception or have difficulty estimating distances accurately? lt .002 .62
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Rank Question P Value Mean difference after treatment
6 Does print blur after reading a short time? lt .002 .62
7 Do you skip lines or lose your place while reading (using your finger or other guide to maintain position on the page)? lt .002 .625
8 Do you tilt your head to one side when reading or working at a desk? lt .002 .62
9 Do you experience dizziness, light-headedness, or nausea associated with close-up activities (i.e., reading, writing, computer work)? lt .0088 .552
10 Do you experience words running together with reading? lt .0090 .379
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Rank Question P Value Mean difference after treatment
11 Do you feel overwhelmed while walking in a large department store (i.e., K-mart, Meijer)? lt .0108 .552
12 Do you experience double vision or overlapping vision at far? lt .0136 .379
13 Do you experience blurred vision with close-up activities (i.e., reading, writing, computer work, sewing)? lt .0208 .552
14 Do you experience dizziness, light-headedness, or nausea associated with far distance activities (i.e., driving, television, movies)? lt .0252 .448
15 Do you experience blurred vision with far-distance activities (i.e., driving, television movies, chalkboard at school)? lt .0298 .552
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Rank Question P Value Mean difference after treatment
16 Do you cover one eye while reading? lt .0365 .310
17 Do you have headache and/or facial pain? lt .053 .517
18 Do you hold reading material too close to your eyes? lt .0572 .345
19 Do you avoid close up tasks? (reading, writing, computer work) lt .0668 .345
20 Do you experience double vision or overlapping at near distance? lt .1095 .241
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Rank Question P Value Mean difference after treatment
21 Do you have pain in your eyes with movement? lt .3053 .172




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Aggregate Results
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Conclusions

• Vertical Heterophoria is a syndrome
• Treatment with fractional units of horizontal and
  vertical prism significantly reduces patient
  symptoms plt .0001
• VHSQ seems to be a useful tool to identify VH
  suspects and measure improvement

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Symptoms Most Improved

• Dizziness on bending down and standing up
• Blinking to clear up distant objects
• Unsteadiness when walking
• Fatigue with reading
• Poor depth perception

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Vertical Heterophoria in Children
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Pediatric Study Design

• Retrospective study of pediatric patients
  comparing and contrasting to adult population

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Pediatric Patient Analysis

• 2/16/05 thru 3/25/06
• 33 children
• 9 lost to f/u
• 3 non-compliant (refused to wear glasses)
• 21 children with complete data
• 7 yo 17 yo, avg 10.4 yo
• 11 boys, 10 girls
• 8 previous eye glass wearers / 14 not

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PMHx / ROS

• Headaches 14 pts
• Dizziness 7
• Motion sickness 6
• Nausea 6
• Tires with reading 6
• Skips lines with reading 6
• ADHD / ADD 5
• Head tilt 4
• Double vision 2
• Anxiety 2

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Prescription Results

• Farsighted 17
• Nearsighted 4
• Pediatricians only routinely test for
  nearsightedness
• 20 out of 21 needed prism
• 20 out of 21 needed bifocal

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VHSQ Results

• Pre-treatment VHSQ score avg 17.9 (range 2-47)
• Post-treatment VHSQ score avg 6.9 (range 1-17)
• Normality tests distribution of differences are
  normally distributed
• Pre-treatment VHSQ is significantly higher than
  post-treatment VHSQ score (plt0.0001, using
  Students t-test)
• Implies that treatment is effective

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Vertical Heterophoria

• Children and adults both have
• Headaches and Dizziness as the primary symptoms
• History of motion sickness
• Difficulty with near point tasks and comprehension

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Impact on School Experience

• Unable to maintain attention on near tasks for
  prolonged periods
• Computer and reading difficulty

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Vertical Heterophoria

• Compared to adults, children have
• Lower VHSQ scores, Pre-treatment and
  post-treatment
• Less need for spectacle prescription
  modifications
• Less anxiety
• More farsightedness

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Headaches

• Head hurts
• Tend to be worse at the end of school days,
  better on weekends
• Frontal, periorbital, temporal, crown, occipital

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Visual Causes of Dizziness

• Riding in a car
• Reading in a car
• Swinging on swings
• Spinning rides at fair
• Postural changes
• Bending down and coming up quickly
• Standing quickly from seated or prone position

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Problems With Depth Perception

• Binocular vision critical for depth perception
• Lack of binocularity causes symptoms
• Feel klutzy and / or uncoordinated
• Walk into friends when walking beside them
• Fall often
• Difficulty with catching a ball
• Bumps into door jambs and furniture

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Vertical Heterophoria in Traumatic Brain Injury
Patients
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Patients

• 83 patients sent for testing
• 77 positive for vertical heterophoria syndrome
• 43 had complete data

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Specialists Seen (78 patients) 3.25 specialists
/ patient range 0-9 specialists /
patient

• IM or FP 64
• Ophtho or Opto 60
• Neuro 47
• ENT 43
• Chiropractor 35
• PMR 23
• Psych 21
• ER 10
• Peds 0.5

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Tests Performed (78 patients) 1.27 tests /
patient range 0-4 tests /
patient

• Brain MRI 43
• HCT 42
• Pt had either had a HCT or MRI 57
• Had both HCT and MRI 27
• Audiogram 22
• ENG 21

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Top 10 Symptoms

• VHSQ questions ranked by number of of positive
  responders AND frequency of symptoms
• (1) 3. Shoulder and neck discomfort
• (2) 1. Headache
• (3) 17. Glare / sensitivity to bright lights
• (4) 4. Dizzy / lightheaded
• (5) 8. Unsteady / drift to one side
• (6) 11. Car rides uncomfortable / dizzy
• (7) 7. Dizziness with provocative head movements
• (8) 13. Head tilt
• (9) 20. Tire easily with close-up tasks
• (10) 23. Blink to clear up distant objects

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Retrospective Data Analysis of 43 TBI Patients
with VH Retrospective
Avg Age Avg Initial VHS-Q score Avg Final VHS-Q Score Avg Subjective Improved
44 M 12 F 31 35 18.3 (47.5 reduction) 72
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Study 2 TBI Study
Number of Patients 43
Mean Age (years) 44
Female Gender 72
1 Average duration of symptoms (years) 3.6 yrs
2 Average duration of treatment (months) 3.5 mos

VHSQ Score (VH Symptom Burden)
Initial 34.8
Final 18.1
3 Reduction with treatment 48

6 Average subjective improvement with Prismatic Lens Treatment using 0-100 numeric rating scale (Subjective Improvement ) 71.8

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Dizziness 2012

• 46 patients 2009-2011
• Chief complaint of dizziness
• Dizziness Handicap Inventory (DHI)
• Headache Disability Index (HDI)
• Zung Anxiety Scale (Zung)
• Vertical Heterophoria Symptom Questionaire (VHSQ)
• 10 cm Visual Analog Scale (VAS)

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Results 2012

• DHI decreased by 51 Plt0.0001
• HDI decreased by 45 Plt0.0001
• VHSQ decreased by 50 Plt0.0001
• Zung decreased by 22 Plt0.0001
• VAS decreased by 71 Plt0.0001

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Phoric Eye Posture in VH
OS
OD
Optics not differentiated in the literature from
Traditional VH (paradigm shift)
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A
B
VH (A orbital asymmetry) Initial pathology affects both eyes
Line of sight / phoric position of high eye is depressed (Initial pathology)
Line of sight / phoric position of low eye is elevated (Initial pathology)
High eye sees high image
High eye is made even higher with head tilt
Driving force is resolution of vertical diplopia
CN 4 / SO Palsy (B CVA, tumor) Initial pathology affects only 1 eye
Line of sight / phoric position of high eye is elevated and extorted (Initial pathology)
Line of sight / phoric position of low eye is straight ahead (normal) and intorted (Secondary pathology)
High eye sees low image
High eye is made even higher with head tilt
Driving force is resolution of torsional / rotational diplopia (still left with vertical disparity)
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Utricle Dysfunction
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Precipitating Events

• Trauma
• Inner ear infection
• Eye surgery
• Mono-vision contacts
• Congenital
• Middle age

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Utricle Dyfunction

• Head tilt
• Vertical misalignment
• Ocular torsion

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Superior semicircular canal

• Works with utricle on vertcal eye posture
• SSCD Superior semicircular canal dehiscence

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Head Roll Tilt

• Tilt to stabilize retinal image and reduce
  diplopia
• Second most destabalized head posture after head
  back
• Semicircular canals, otoliths, eyes are not in
  proper alignment with gravity
• Change in center of gravity

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Head Tilt

• Destabilize balance and posture
• Inner ear and eyes not in normal plane
• Induction of vertical optokinetic nytagmus on
  motion

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Foot Posture

• Feet position change with prism
• Toe in versus toe out

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Vertical Eye Height Imbalance

• 30 of the population has one eye higher than the
  other
• 4 of the population has Vertical Herterophoria

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Retinal Slip

• Eye misalignment and head tilt causes image to
  be off center of fovea
• Eye muscles are constantly trying to align images
• Transient diplopia from muscle fatigue
• Similar to menieres with a constantly changing
  sensory input
• Muscle pain mediated through V1 and V2

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Visual Preference for Balance

• Aldopho Bronstein
• Visual Vertigo

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Motion Sickness

• Vertical optico-kinetic nystagmus
• Associated roll tilt
• Combined with vertical eye skew
• Asymmetric optico-kinetic nystagmus in time and
  angle
• Utricle dysfunction
• Visual preference for balance

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Hierarchy of Balance

• Staying upright
• Binocular vision
• Roll head tilt
• Ocular torsion

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Menieres Disese of the eye

• Fluctuation of visual image causes symptoms
• Prevents compensation
• Translational vestibulo-occulo reflex vs
  rotational vestibulo-occulo reflex

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Feel like falling

• Translational VOR
• Rotational VOR
• Switching between visual and vestibular system

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Medications

• Neurology of eye movements, John Leigh, and
  David Zee

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Pathophysiology

• Combination of vertical misalignment of the
  eyes, head tilt, utricle dysfunction, and a
  visual preference for balance causes symptoms

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VNG findings

• Pursuit
• Saccade
• Optiko-kinetic
• May have unilateral weakness or directional
  preponderance
• Central vertigo

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Vestibular evoked myogrenic potential

• Occular VEMP utricle
• Cervical VEMP saccule
• Stimuli tone or vibration

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C-VEMP
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O-VEMP
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Saccule

• Balance when supine or prone
• Autonomic dysfunction
• Postural hypotention
• Aging
• Pots Syndrome

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Vestibular Therapy

• Model from speech therapy
• Therapy targeted to VNG and VEMP test results

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Vestibular therapy

• Utricle dysfunction
• Saccule dysfunction
• Pursuit abnormalities
• Saccade abnormality
• Optokinetic dysfunction motion sickness
• Caloric loss

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Vestibular therapy

• Roll tilt
• Leg lenth abnormality
• Pelvic assymetry
• Numbness of feet
• Low vison

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Vestibular therapy

• Hearing loss

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Acute Vertical Heterophoria Syndrome

• Often associated with Benign paroxysmal
  positional vertigo
• Can be associated with vestibular neuronitis
• Often hospitalized
• Treated differently

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• Who, indeed, could have supposed that a mere
  ocular defect could have given rise to so serious
  a train of evilsand who that had not seen it
  could believe that the correction by glasses of
  the eye trouble could have given a relief so
  speedy and so perfect that the patient herself
  described it as a miracle?
• S. Weir Mitchell, Headaches and Eye Strain April
  1876 (13)

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Thank you

• Angie Mcnab (Lederman)
• Cheryl Wilson

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