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   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

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

  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 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: 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 Patients with glasses 25 29 Patients with vertical prism to correct a high left eye and horizontal base-in prism

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 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

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

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

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

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

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

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 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% PM&R 23% Psych 21% ER 10% Peds 0.5%

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

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 Initial VHS-Q score Final VHS-Q Score Subjective % Improved 44 M = 12 F = 31 35 18.3 (47.5% reduction) 72% 57 57

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 0-100 numeric rating scale (Subjective Improvement %) 71.8% 58

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 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)

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)

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