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Rethinking Dizziness The Role of Vision, Utricle, and Saccule Arthur Rosner, MD FACS Debby Feinberg, OD Mark Rosner, MD FACEP John Kemink MD, 1949-1992 Shiro Fujita Listen to the Patient How it Started Current Diagnosis Failure to compensate Non-vertiginous dizziness Mal debarquement syndrome Mall patient Visual vertigo dyslexia Current diagnosis Vestibular Migraine Vomiting with anesthesia Motion sickness Central vertigo Neck pain Anxiety Current diagnosis Meniere’s Disease Agoraphobia Bilateral vestibular loss Vomiting on VNG Prevalence 4% of my practice has binocular vision dysfunction Over 8000 patients have been treated Optometrists now trained in other states 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. History 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 Vision Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005. Symptoms Dizziness 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 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 Trigeminal nerve Trigeminal nerve Otolaryngology 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 Design Otolaryngology examination Pre-treatment Vertical Heterophoria Symptom Questionnaire (VHSQ) Optometry examination Eyeglasses with corrected prescription including vertical and horizontal prism Post-treatment VHSQ 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 Demographics 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 Chief Complaint on Presentation to the Otolaryngologist 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 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 Evaluation Functional 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 eye 2PD/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 PD Recovery: 1.5-2 PD Trial Frame 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 Prescription Before Treatment After 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 Statistics Likert scale 0 = Never 1 = Occasionally 2 = Frequently 3 = always Paired t-test before and after treatment For each question Total questionnaire score 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 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 < .0001 desk or with near centered tasks? .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 < .0088 .552 associated with close-up activities (i.e., reading, writing, computer work)? 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 < .0108 store (i.e., K-mart, Meijer)? .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 < .3053 .172 Do you have pain in your eyes with movement? Aggregate 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 Posttreatment 11.0 P< .0001 Conclusions Vertical Heterophoria is a syndrome Treatment 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 Improved Dizziness on bending down and standing up Blinking to clear up distant objects Unsteadiness when walking Fatigue with reading Poor depth perception Vertical Heterophoria in Children Pediatric Study Design Retrospective study of pediatric patients comparing and contrasting to adult population 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 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 Prescription Results Farsighted = 17 Nearsighted = 4 Pediatricians only routinely test for nearsightedness 20 out of 21 needed prism 20 out of 21 needed bifocal 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 (p<0.0001, using Student’s t-test) Implies that treatment is effective 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 Impact on School Experience Unable to maintain attention on near tasks for prolonged periods: – Computer and reading difficulty 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 Headaches “Head hurts” Tend to be worse at the end of school days, better on weekends Frontal, periorbital, temporal, crown, occipital 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 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 Vertical Heterophoria in Traumatic Brain Injury Patients Patients 83 patients sent for testing 77 positive for vertical heterophoria syndrome 43 had complete data Specialists Seen (78 patients): 3.25 specialists / patient range: 0-9 specialists / patient IM or FP Ophtho or Opto Neuro ENT Chiropractor PM&R Psych ER Peds 64% 60% 47% 43% 35% 23% 21% 10% 0.5% Tests Performed 1.27 tests / patient Brain MRI HCT Audiogram ENG : range: 0-4 tests / patient 43% 42% – Pt had either had a HCT or MRI – Had both HCT and MRI (78 patients) 22% 21% 57% 27% 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 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 35 18.3 72% (47.5% reduction) M = 12 F = 31 Study 2: TBI Study 1 2 3 6 Number of Patients Mean Age (years) Female Gender Average duration of symptoms (years) Average duration of treatment (months) VHSQ Score (VH Symptom Burden): Initial Final Reduction with treatment Average subjective improvement with Prismatic Lens Treatment using 0-100 numeric rating scale (Subjective Improvement %) 43 44 72% 3.6 yrs 3.5 mos 34.8 18.1 48% 71.8% 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) Results 2012 DHI decreased by 51% P<0.0001 HDI decreased by 45% P<0.0001 VHSQ decreased by 50% P<0.0001 Zung decreased by 22% P<0.0001 VAS decreased by 71% P<0.0001 Phoric Eye Posture in VH Fovea T Orthophoria Traditional Vertical Heterophoria (CN4 / SO palsy) *Vertical Heterophoria due to vertical orbital misalignment *Vertical Heterophoria due TBI *Optics not differentiated in the literature from Traditional VH (paradigm shift) OS OD A B VH (A – orbital asymmetry) – Initial pathology CN 4 / SO Palsy (B – CVA, tumor) – Initial pathology affects both eyes affects only 1 eye Line of sight / phoric position of high eye is depressed (Initial pathology) Line of sight / phoric position of high eye is elevated and extorted (Initial pathology) Line of sight / phoric position of low eye is elevated (Initial pathology) Line of sight / phoric position of low eye is straight ahead (normal) and intorted (Secondary pathology) High eye sees high image High eye sees low image High eye is made even higher with head tilt* High eye is made even higher with head tilt* *Driving force is resolution of vertical diplopia *Driving force is resolution of torsional / rotational diplopia (still left with vertical disparity) Utricle Dysfunction Precipitating Events Trauma Inner ear infection Eye surgery Mono-vision contacts Congenital Middle age Utricle Dyfunction Head tilt Vertical misalignment Ocular torsion Superior semicircular canal Works with utricle on vertcal eye posture SSCD Superior semicircular canal dehiscence 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 Head Tilt Destabilize balance and posture Inner ear and eyes not in normal plane Induction of vertical optokinetic nytagmus on motion Foot Posture Feet position change with prism Toe in versus toe out Vertical Eye Height Imbalance 30% of the population has one eye higher than the other 4% of the population has Vertical Herterophoria 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 meniere’s with a constantly changing sensory input Muscle pain mediated through V1 and V2 Visual Preference for Balance Aldopho Bronstein Visual Vertigo 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 Hierarchy of Balance Staying upright Binocular vision Roll head tilt Ocular torsion Menieres Disese of the eye Fluctuation of visual image causes symptoms Prevents compensation Translational vestibulo-occulo reflex vs rotational vestibulo-occulo reflex Feel like falling Translational VOR Rotational VOR Switching between visual and vestibular system Medications Neurology of eye movements, John Leigh, and David Zee Pathophysiology Combination of: vertical misalignment of the eyes, head tilt, utricle dysfunction, and a visual preference for balance causes symptoms VNG findings Pursuit Saccade Optiko-kinetic May have unilateral weakness or directional preponderance Central vertigo Vestibular evoked myogrenic potential Occular VEMP utricle Cervical VEMP saccule Stimuli tone or vibration C-VEMP O-VEMP Saccule Balance when supine or prone Autonomic dysfunction Postural hypotention Aging Pots Syndrome Vestibular Therapy Model from speech therapy Therapy targeted to VNG and VEMP test results Vestibular therapy Utricle dysfunction Saccule dysfunction Pursuit abnormalities Saccade abnormality Optokinetic dysfunction motion sickness Caloric loss Vestibular therapy Roll tilt Leg lenth abnormality Pelvic assymetry Numbness of feet Low vison Vestibular therapy Hearing loss Acute Vertical Heterophoria Syndrome Often associated with Benign paroxysmal positional vertigo Can be associated with vestibular neuronitis Often hospitalized Treated 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 you Angie Mcnab (Lederman) Cheryl Wilson