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