rethinking dizziness the role of vision, utricle, and saccule arthur rosner, md facs debby feinberg,...
TRANSCRIPT
Rethinking DizzinessRethinking DizzinessThe Role of Vision, Utricle, and The Role of Vision, Utricle, and
Saccule Saccule
Arthur Rosner, MD FACS
Debby Feinberg, OD
Mark Rosner, MD FACEP
John Kemink MD, 1949-1992John Kemink MD, 1949-1992
Shiro FujitaShiro FujitaListen to the PatientListen to the Patient
How it StartedHow it Started
Current DiagnosisCurrent Diagnosis
Failure to compensateNon-vertiginous dizzinessMal debarquement syndromeMall patientVisual vertigodyslexia
Current diagnosisCurrent diagnosis
Vestibular MigraineVomiting with anesthesiaMotion sicknessCentral vertigoNeck painAnxiety
Current diagnosisCurrent diagnosis
Meniere’s DiseaseAgoraphobiaBilateral vestibular lossVomiting on VNG
PrevalencePrevalence
4% of my practice has binocular vision dysfunction
Over 8000 patients have been treatedOptometrists now trained in other states
Vertical HeterophoriaVertical 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.
HistoryHistory
Von Graefe. A Uber musculaire Asthenopic. Arch Opthal 1862;8:314-367.
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 2010;2:244-253.
Transient Diplopia or Blurred Transient Diplopia or Blurred VisionVision
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.
SymptomsSymptomsDizziness
Headache
Head Tilt
Nausea
Agoraphobia
Anxiety
Motion sickness
Unsteady while walking
Problems reading
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.
Anxiety Symptoms Associated Anxiety Symptoms Associated with with
DizzinessDizziness
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
Trigeminal nerveTrigeminal nerve
Trigeminal nerveTrigeminal nerve
Otolaryngology ExaminationOtolaryngology Examination
Head Tilt
Vertical and horizontal disparity between the eyes
Convergence insufficiency
Duplication of symptoms on eye movements
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.
Study DesignStudy Design
Otolaryngology examinationPre-treatment Vertical Heterophoria
Symptom Questionnaire (VHSQ)Optometry examinationEyeglasses with corrected prescription
including vertical and horizontal prismPost-treatment VHSQ
Inclusion and Exclusion Inclusion and Exclusion CriteriaCriteria
100 patients sent for optometry evaluation60 patients seen by the optometrist39 patients filled out pre and post
questionnaires29 patients with vertical heterophoria
treated with prism
Number of patients from the study group
Female 25
Male 4
Prior prescription eyeglasses 25
Trouble adjusting to prior eyeglasses 9
Prior history of eye muscle imbalance or prior prism 4
Migraine history 7
Concomitant benign paroxysmal positional vertigo at initial office visit, which resolved with Eply maneuver
4
DemographicsDemographics
Number of patients with a chief complaint of dizziness
Number of patients with a chief complaint of sinus headache
Number of patients with a chief complaint of both dizziness and headache
At initial presentation
16 7 6
Results from questionnaire before treatment
7 1 21
Chief Complaint on Chief Complaint on Presentation to the Presentation to the
OtolaryngologistOtolaryngologist
Number of patients from the study group
MRI of the head 8 All normal except for minimal mucosal thickening
CT scan of the head 6 All normal except for minimal mucosal thickening
Audiogram total 9
Audiogram normal 5
Bilateral symmetrical low frequency sensorineural hearing loss
1
Bilateral symmetrical high frequency sensorineural hearing loss
2
Asymmetric high frequency sensorineural hearing loss with normal MRI
Elecronystagmogram total 6
Elecronystagmogram normal 4
Elecronystagmogram abnormal 2 abnormal optokinetic nystagmus
Optometry EvaluationOptometry EvaluationFunctional Vision Tests
Average Results Range of Results Expected Findings
Vertical Distance Phoria
.5PD base-up left eye
0-1.5 PD base-up left eye Ortho or 0
Vertical Near Phoria
1PD base-up left eye
1 PD base-down left eye-3.5PD base-up left eye
Ortho or 0
Vertical Vergence at Near
4 PD/2PD base up left eye2PD/0PD base down left eye
4PD/1PD base up left eye; 5PD/1PD base down left eye -7PD/4PD base up left eye;2PD/0PD base down left eye
Break: 3-4 PDRecovery: 1.5-2 PD
Trial FrameTrial Frame
Trial FramingTrial Framing
Dynamic process between patient and doctorQuarter unit prism lenses are required Time needed between adjustments to allow
muscles in eyes and neck to relaxPrescription modified based on the patients
responseNeeds to be learned in person
PrescriptionPrescriptionBefore
TreatmentAfter
Treatment
Patients with bifocals 10 27
Patients with myopia 18 19
Patients with hyperopia 5 9
Patients with astigmatism 18 27
Patients with glasses 25 29
Patients with vertical prism to correct a high left eye and horizontal base-in prism
0 25
StatisticsStatistics
Likert scale 0 = Never 1 = Occasionally 2 = Frequently 3 = always
Paired t-test before and after treatment
For each question Total questionnaire
score
Optometric ExaminationOptometric Examination
Standard optometric examPhoria testing, vertical vergence, and
Maddox rod tests do not predict the need for prism, amount of prism or direction of prism
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?
< .0001 .8271
2 Do you blink to “clear up” distant objects after working at a desk or with near centered tasks?
< .0001 .8271
3 Do you feel unsteady with walking? < .0001 .758
4 Do you tire easy with reading? < .0014 .724
5 Do you experience poor depth perception or have difficulty estimating distances accurately?
< .002 .62
Rank Question P Value
Mean difference after treatment
6 Does print blur after reading a short time? < .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)?
< .002 .625
8 Do you tilt your head to one side when reading or working at a desk?
< .002 .62
9 Do you experience dizziness, light-headedness, or nausea associated with close-up activities (i.e., reading, writing, computer work)?
< .0088 .552
10 Do you experience words running together with reading? < .0090 .379
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)?
< .0108 .552
12 Do you experience double vision or overlapping vision at far? < .0136 .379
13 Do you experience blurred vision with close-up activities (i.e., reading, writing, computer work, sewing)?
< .0208 .552
14 Do you experience dizziness, light-headedness, or nausea associated with far distance activities (i.e., driving, television, movies)?
< .0252 .448
15 Do you experience blurred vision with far-distance activities (i.e., driving, television movies, chalkboard at school)?
< .0298 .552
Rank Question P Value Mean difference after treatment
16 Do you cover one eye while reading? < .0365 .310
17 Do you have headache and/or facial pain? < .053 .517
18 Do you hold reading material too close to your eyes? < .0572 .345
19 Do you avoid close up tasks? (reading, writing, computer work)
< .0668 .345
20 Do you experience double vision or overlapping at near distance?
< .1095 .241
Rank Question P Value Mean difference after treatment
21 Do you have pain in your eyes with movement? < .3053 .172
Aggregate ResultsAggregate Results Lowest Score Highest Score Average Score
Pre-Treatment Questionnaire Score
7 47 21.5
Post-Treatment Questionnaire Score
0 30 10.5
Difference in questionnaire score Pre-treatment to Post-treatment
11.0P< .0001
ConclusionsConclusions
Vertical Heterophoria is a syndromeTreatment with fractional units of
horizontal and vertical prism significantly reduces patient symptoms p< .0001
VHSQ seems to be a useful tool to identify VH suspects and measure improvement
Symptoms Most ImprovedSymptoms Most Improved
Dizziness on bending down and standing upBlinking to clear up distant objects Unsteadiness when walking Fatigue with reading Poor depth perception
Vertical Vertical Heterophoria in Heterophoria in
ChildrenChildren
Pediatric Study DesignPediatric Study Design
Retrospective study of pediatric patients comparing and contrasting to adult population
Pediatric Patient AnalysisPediatric 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
PMHx / ROSPMHx / 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
Prescription ResultsPrescription Results
Farsighted = 17 Nearsighted = 4 Pediatricians only routinely test for
nearsightedness
20 out of 21 needed prism 20 out of 21 needed bifocal
VHSQ ResultsVHSQ 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 (p<0.0001, using Student’s t-test)
Implies that treatment is effective
Vertical HeterophoriaVertical Heterophoria
Children and adults both have:– Headaches and Dizziness as the primary
symptoms– History of motion sickness– Difficulty with near point tasks and
comprehension
Impact on School Impact on School ExperienceExperience
Unable to maintain attention on near tasks for prolonged periods:– Computer and reading difficulty
Vertical HeterophoriaVertical Heterophoria
Compared to adults, children have: – Lower VHSQ scores, Pre-treatment and post-
treatment– Less need for spectacle prescription
modifications– Less anxiety– More farsightedness
HeadachesHeadaches
“Head hurts”Tend to be worse at the end of school days,
better on weekendsFrontal, periorbital, temporal, crown,
occipital
Visual Causes of DizzinessVisual 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
Problems With Depth Problems With Depth PerceptionPerception
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
Vertical Heterophoria in Vertical Heterophoria in Traumatic Brain Injury Traumatic Brain Injury
PatientsPatients
PatientsPatients
83 patients sent for testing77 positive for vertical heterophoria
syndrome43 had complete data
Specialists Seen Specialists Seen (78 patients)(78 patients):: 3.25 specialists / patient3.25 specialists / patient range: 0-9 specialists / range: 0-9 specialists /
patientpatient
IM or FP 64% Ophtho or Opto 60% Neuro 47% ENT 43% Chiropractor 35% PM&R 23% Psych 21% ER 10% Peds 0.5%
Tests PerformedTests Performed (78 patients)(78 patients):: 1.27 tests / patient1.27 tests / patient range: 0-4 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%
Top 10 SymptomsTop 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
Retrospective Data Analysis Retrospective Data Analysis of 43 TBI Patients with VH of 43 TBI Patients with VH
Retrospective Retrospective
Avg Avg AgeAge
Avg Avg Initial VHS-Q scoreInitial VHS-Q score
Avg Avg Final VHS-Q ScoreFinal VHS-Q Score
Avg Avg Subjective % ImprovedSubjective % Improved
4444M = 12M = 12F = 31F = 31
3535 18.318.3(47.5% reduction)(47.5% reduction)
72%72%
Study 2: TBI Study
Number of Patients 43Mean Age (years) 44Female 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%
Dizziness 2012Dizziness 2012
46 patients 2009-2011Chief 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)
Results 2012Results 2012
DHI decreased by 51% P<0.0001HDI decreased by 45% P<0.0001VHSQ decreased by 50% P<0.0001Zung decreased by 22% P<0.0001VAS decreased by 71% P<0.0001
OD
OS
Traditional Vertical Heterophoria
(CN4 / SO palsy)
*Vertical Heterophoria due to vertical orbital misalignment
*Optics not differentiated in the literature from Traditional VH (paradigm shift)
OrthophoriaFovea T
Phoric Eye Posture in VHPhoric Eye Posture in VH
*Vertical Heterophoria due TBI
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
A
B
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)
Utricle DysfunctionUtricle Dysfunction
Precipitating EventsPrecipitating Events
TraumaInner ear infectionEye surgeryMono-vision contactsCongenitalMiddle age
Utricle DyfunctionUtricle Dyfunction
Head tiltVertical misalignmentOcular torsion
Superior semicircular canalSuperior semicircular canal
Works with utricle on vertcal eye postureSSCD Superior semicircular canal
dehiscence
Head Roll TiltHead 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
Head TiltHead Tilt
Destabilize balance and postureInner ear and eyes not in normal planeInduction of vertical optokinetic nytagmus
on motion
Foot PostureFoot Posture
Feet position change with prismToe in versus toe out
Vertical Eye Height ImbalanceVertical Eye Height Imbalance
30% of the population has one eye higher than the other
4% of the population has Vertical Herterophoria
Retinal SlipRetinal 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 meniere’s with a constantly changing
sensory input Muscle pain mediated through V1 and V2
Visual Preference for BalanceVisual Preference for Balance
Aldopho BronsteinVisual Vertigo
Motion SicknessMotion Sickness
Vertical optico-kinetic nystagmusAssociated roll tiltCombined with vertical eye skewAsymmetric optico-kinetic nystagmus in
time and angleUtricle dysfunctionVisual preference for balance
Hierarchy of BalanceHierarchy of Balance
Staying uprightBinocular visionRoll head tiltOcular torsion
Menieres Disese of the eyeMenieres Disese of the eye
Fluctuation of visual image causes symptoms
Prevents compensationTranslational vestibulo-occulo reflex vs
rotational vestibulo-occulo reflex
Feel like fallingFeel like falling
Translational VORRotational VORSwitching between visual and vestibular
system
MedicationsMedications
Neurology of eye movements, John Leigh, and David Zee
PathophysiologyPathophysiology
Combination of: vertical misalignment of the eyes, head tilt, utricle dysfunction, and a visual preference for balance causes symptoms
VNG findingsVNG findings
PursuitSaccadeOptiko-kineticMay have unilateral weakness or directional
preponderance Central vertigo
Vestibular evoked myogrenic Vestibular evoked myogrenic potentialpotential
Occular VEMP utricleCervical VEMP sacculeStimuli tone or vibration
C-VEMPC-VEMP
O-VEMPO-VEMP
SacculeSaccule
Balance when supine or proneAutonomic dysfunctionPostural hypotentionAgingPots Syndrome
Vestibular TherapyVestibular Therapy
Model from speech therapyTherapy targeted to VNG and VEMP test
results
Vestibular therapyVestibular therapy
Utricle dysfunctionSaccule dysfunctionPursuit abnormalitiesSaccade abnormalityOptokinetic dysfunction motion sicknessCaloric loss
Vestibular therapyVestibular therapy
Roll tiltLeg lenth abnormalityPelvic assymetryNumbness of feetLow vison
Vestibular therapyVestibular therapy
Hearing loss
Acute Vertical Heterophoria Acute Vertical Heterophoria SyndromeSyndrome
Often associated with Benign paroxysmal positional vertigo
Can be associated with vestibular neuronitisOften hospitalizedTreated differently
“Who, indeed, could have supposed that a mere ocular defect could have given rise to so serious a train of evils…and 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)
Thank youThank you
Angie Mcnab (Lederman)Cheryl Wilson