1. Rethinking Dizziness The Role of Vision, Utricle, and Saccule
Arthur Rosner, MD FACS
Debby Feinberg, OD
Mark Rosner, MD FACEP

2. John Kemink MD,

3. Shiro Fujita Listen to the Patient

4. How it Started

5. Current Diagnosis Failure to compensate Non-vertiginous dizziness
Mal debarquement syndrome
Mall patient
Visual vertigo
dyslexia

6. Current diagnosis Vestibular Migraine Vomiting with anesthesia
Motion sickness
Central vertigo
Neck pain
Anxiety

7. Current diagnosis Meniere’s Disease Agoraphobia
Bilateral vestibular loss
Vomiting on VNG

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

9. 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.

11. History
Von Graefe. A Uber musculaire Asthenopic. Arch Opthal 1862;8:
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:

12. Transient Diplopia or Blurred Vision
Thierry M. Using Prism Graphics. Detroit Free Press. August 2, 2005.

13. 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.

14. 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

15. Trigeminal nerve

16. Trigeminal nerve

17. 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.

19. 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

20. 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

21. Demographics Number of patients from the study group Female 25 Male 4
Number of patients from the study group
Female 25
Male 4
Prior prescription eyeglasses
Trouble adjusting to prior eyeglasses 9
Prior history of eye muscle imbalance or prior prism
Migraine history 7
Concomitant benign paroxysmal positional vertigo at initial office visit, which resolved with Eply maneuver

22. 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 1 21

23. 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

24. 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
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;
Break: 3-4 PD
Recovery: PD

25. Trial Frame

26. 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

27. Prescription Before Treatment After Treatment Patients with bifocals10 27
Patients with myopia 18 19
Patients with hyperopia 5 9
Patients with astigmatism
Patients with glasses 25 29
Patients with vertical prism to correct a high left eye and horizontal base-in prism

28. Statistics Likert scale 0 = Never 1 = Occasionally 2 = Frequently
3 = always
Paired t-test before and after treatment
For each question
Total questionnaire score

29. 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

30. 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? 3
Do you feel unsteady with walking?
.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

31. 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)?
.625 8
Do you tilt your head to one side when reading or working at a desk? 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

32. 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 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

33. 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 20
Do you experience double vision or overlapping at near distance?
< .1095
.241

34. Rank
Question
P Value
Mean difference after treatment 21
Do you have pain in your eyes with movement?
< .3053
.172

35. Aggregate Results Lowest Score Highest Score Average Score
Lowest Score
Highest Score
Average Score
Pre-Treatment Questionnaire Score 7 47
21.5
Post-Treatment Questionnaire Score 30
10.5
Difference in questionnaire score
Pre-treatment to Post-treatment
11.0
P< .0001

36. 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

37. 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

39. Vertical Heterophoria in Children

41. Pediatric Study Design
Retrospective study of pediatric patients comparing and contrasting to adult population

42. 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

43. 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

44. Prescription Results Farsighted = 17 Nearsighted = 4
Pediatricians only routinely test for nearsightedness
20 out of 21 needed prism
20 out of 21 needed bifocal

45. 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

46. 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

47. Impact on School Experience
Unable to maintain attention on near tasks for prolonged periods:
Computer and reading difficulty

48. 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

49. Headaches “Head hurts”
Tend to be worse at the end of school days, better on weekends
Frontal, periorbital, temporal, crown, occipital

50. 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

51. 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

52. Vertical Heterophoria in Traumatic Brain Injury Patients

53. Patients 83 patients sent for testing
77 positive for vertical heterophoria syndrome
43 had complete data

54. Specialists Seen (78 patients): 3. 25 specialists / patient
Specialists Seen (78 patients): specialists / patient range: 0-9 specialists / patient
IM or FP 64%
Ophtho or Opto 60%
Neuro 47%
ENT 43%
Chiropractor 35%
PM&R 23%
Psych 21%
ER 10%
Peds 0.5%

55. Tests Performed (78 patients): 1. 27 tests / patient
Tests Performed (78 patients): 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%

56. 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

57. Retrospective Data Analysis of 43 TBI Patients with VH Retrospective
Avg
Age
Initial VHS-Q score
Final VHS-Q Score
Subjective % Improved 44
M = 12
F = 31 35
18.3
(47.5% reduction)
72% 57 57

58. Average duration of symptoms (years) 3.6 yrs 2
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 numeric rating scale (Subjective Improvement %)
71.8% 58

61. 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)

62. 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

63. Phoric Eye Posture in VH
Orthophoria
Fovea T
Traditional Vertical Heterophoria
(CN4 / SO palsy) OS
*Vertical Heterophoria due to vertical orbital misalignment OD
*Vertical Heterophoria due TBI
*Optics not differentiated in the literature from Traditional VH (paradigm shift)

65. 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)

69. Utricle Dysfunction

70. Precipitating Events Trauma Inner ear infection Eye surgery
Mono-vision contacts
Congenital
Middle age

71. Utricle Dyfunction
Head tilt
Vertical misalignment
Ocular torsion

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

74. 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

75. Head Tilt Destabilize balance and posture
Inner ear and eyes not in normal plane
Induction of vertical optokinetic nytagmus on motion

76. Foot Posture
Feet position change with prism
Toe in versus toe out

77. Vertical Eye Height Imbalance
30% of the population has one eye higher than the other
4% of the population has Vertical Herterophoria

78. 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

79. Visual Preference for Balance
Aldopho Bronstein
Visual Vertigo

80. 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

81. Hierarchy of Balance Staying upright Binocular vision Roll head tilt
Ocular torsion

82. Menieres Disese of the eye
Fluctuation of visual image causes symptoms
Prevents compensation
Translational vestibulo-occulo reflex vs rotational vestibulo-occulo reflex

83. Feel like falling Translational VOR Rotational VOR
Switching between visual and vestibular system

84. Medications
Neurology of eye movements, John Leigh, and David Zee

85. Pathophysiology
Combination of: vertical misalignment of the eyes, head tilt, utricle dysfunction, and a visual preference for balance causes symptoms

86. VNG findings Pursuit Saccade Optiko-kinetic
May have unilateral weakness or directional preponderance
Central vertigo

87. Vestibular evoked myogrenic potential
Occular VEMP utricle
Cervical VEMP saccule
Stimuli tone or vibration

88. C-VEMP

89. O-VEMP

94. Saccule Balance when supine or prone Autonomic dysfunction
Postural hypotention
Aging
Pots Syndrome

95. Vestibular Therapy Model from speech therapy
Therapy targeted to VNG and VEMP test results

96. Vestibular therapy Utricle dysfunction Saccule dysfunction
Pursuit abnormalities
Saccade abnormality
Optokinetic dysfunction motion sickness
Caloric loss

97. Vestibular therapy Roll tilt Leg lenth abnormality Pelvic assymetry
Numbness of feet
Low vison

98. Vestibular therapy
Hearing loss

99. Acute Vertical Heterophoria Syndrome
Often associated with Benign paroxysmal positional vertigo
Can be associated with vestibular neuronitis
Often hospitalized
Treated differently

100. “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)

101. Thank you
Angie Mcnab (Lederman)
Cheryl Wilson