Citation: Guerraz, M., Yardley, L., et al. Visual vertigo: symptom assessment, spatial orientation and postural control. Oxford University Press 2001; 124: 1646-1656
Summarized by: Amy M. Bartal, O.D. Resident, Vision Therapy and Rehabilitation EyeCare Professionals, PC Hamilton, NJ
(A Southern College of Optometry,Private Practice Residency)
Summary: The purpose of this article is to determine the cause of visual vertigo by assessing symptoms, spatial orientation, and postural control.
Methods: Twenty one individuals were identified with visual vertigo (VV) after reporting worsening of symptoms including vertigo, dizziness, unsteadiness or spatial disorientation by certain visual surroundings. These patients were compared with visually dependent individuals with a bilateral labyrinthine-defective (LDS) disorder, and normal subjects using questionnaires and experimental stimuli. All subjects answered several surveys including the Situational Vertigo Questionnaire, Vertigo Symptom Scale, Childhood Motion Sickness Questionnaire, Spielberger Trait Anxiety Inventory, and Vertigo Handicap Questionnaire. These surveys measured patient symptoms, level of anxiety, and experiences with motion sickness for all groups. The experimental stimuli required the subjects to orient a linear rod vertically while in three settings: darkness, within a tilted frame, and within a rotating disc. Body sway was also measured in four visual conditions. Subjects were instructed to stand bare-foot on a force platform and fixate on a luminescent dot with their eyes opened, eyes closed, while the target was located within a tilted frame or a rotating disc. The data measured formed two computed quotients. The Romberg quotient (RQ = eyes closed sway/eyes opened sway) reflects the amount of postural instability with stationary visual surroundings. The visual-kinetic quotient (V-KQ = rotating disc sway/eyes open sway) quantifies the destabilizing effect of moving stimuli. Statistical analysis was based on a multi-way analysis of variance and co-variance for the questionnaire data and the visual vertical and postural data, respectively.
Results: The data collected through the subject questionnaires revealed significantly higher levels of visually induced anxiety symptoms in the VV and LDS patients compared to the normal controls. The VV subjects also had significantly higher levels of vertigo. There were no statistical differences found correlating childhood motion sickness or levels of handicaps felt with the different experimental groups. In the subjective visual vertical and postural tests, both the VV and LDS patients demonstrated an increase in tilt of the vertical rod both with the static tilted frame and the rotating disc. Postural deviation when facing the titled frame and rotating disc was also increased in both of these groups. When comparing the stabilizing effect of vision there was a statistical increase in the LDS subjects but not the VV when compared to the controls. In contrast, the destabilizing effect of a moving visual stimulus had a greater impact on the VV subjects and not the LDS patients.
In conclusion, VV patients have an abnormally large perceptual and postural response to disorienting visual environments. VV develops in individuals who are visually dependent and rely on visual cues more than vestibulo-proprioceptive inputs. Treatment is aimed at increasing subjective and postural tolerance to disorienting visual stimuli and increasing the patients’ use of vestibulo-proprioceptive cues. Repetitive optokinetic stimulation has shown improvement in postural stability and patient symptoms.
Case in Point: A 43 year old woman presented to our office 2.5 years ago with symptoms of headaches and vertigo that was exacerbated by certain visual environments such as shopping malls, supermarkets with tall aisles, and in general all fluorescent lighting. Her history included several minor traumatic brain injuries (auto accident, hitting her head on a shelf, etc) non of which caused loss of consciousness, or required hospitalization.
Examination revealed a diagnosis of mild convergence excess. The rest of the ocular health and visual examination was unremarkable with the notable exception that viewing an Optokinetic drum caused tremendous increase in symptomatology. This occured whether the OKN drum was spinning or not and even occured when the drum was diplaced from the patient’s line of sight (left side placement was the worst). Critical Flicker Frequency was atypically high (her threshold was about 50Hz, average patients are in the 43-45Hz range). This means that her sensitivity to flicker was very high.
Our treatment plan revolved around prescribing a therapeutic tint (she responded positively to a BPI Omega tint-purplish hue). Upon eyeglass dispensing she reported that the glasses allowed her the first headache-free, non-vertigo day in over 2 years.
Vision therapy centered around restoring fusional vergence to normal levels and gradually introducing eye movement procedures for fixation, pursuit, and saccades that required greater speed, visual motor integration, and cognitve distractors. The vision therapy (along with the tinted spectacles) proved to reduce her symptoms dramatically. Other intervention that the patient felt was helpful was Logan chiropractic treatment, B complex vitamins, and increasing sleep to 8 hours per evening.
We recently saw her one year after post vision therapy and she maintains that she is almost symptom free virtually every day.
Hi—nice job! Very important area for optometry and in particular brain injury, but unfortunately with relatively few publications. It reminded me of a short paper I published on the same topic involving a patient that Hal Friedman referred to me (Ciuffreda, KJ, ‘Visual vertigo syndrome: clinical demonstration and diagnostic tool’, Clinical Eye and Vision Care, 11:41-42, 1999), which you can google and download, as well as a poster that a neurologist (Joyce Ilson) and I presented at ARVO a few years ago, but have not yet published. Basically, three tests were very high yield in this population with VVS, or the ‘supermarket syndrome’as it has been called—these patients cannot stand to go to a large supermarket or department store due to all of the movement: repeated NPC; use of an OKN drum NOT to elicit OKN per se but to re-create the visual motion flow on the retina (i.e., Gibsonian optic flow); the drum is held a few inches away from the center of the face, or more on the side of the face, and rotated pretty slowly—the response can be dramatic!!!, ranging from extreme displeasure to near vomiting!; and neck vibration using any sort of vibrator with eyes opened—we used ones for 99 cents!—again when you get a response, it is pretty dramatic—the world tilts, near vomiting, disorientation, extreme displeasure, etc. Lastly, Pat Winkler and I published a paper in Optometry last year on a similar topic, which was part of her Ph.D. thesis.
Excellent insights, Ken. Thanks for sharing that info.
Ken, thanks for commenting and especially the references for VVS. Glad you mentioned neck vibration; another diagnostic test that hardly anyone knows about that can yield very significant results!
thanks! I learned a lot in reading this article! kudos!
“The true genius shudders at incompleteness – and usually prefers silence to saying something which is not everything it should be.”
Edgar Allan Poe
You’re welcome. I’m glad it was helpful to you!
Terrific! Thanks for letting me know.
Very well done, Dr. Bartal! On a related note, take a look at: https://visionhelp.wordpress.com/2010/10/05/parlez-vous-vision-therapy-part-2/
Regards – Dr. L. Press
Thanks Dr. Press! That was a great article review. It is interesting to see how vergence problems and uncorrected hyperopia can cause symptoms of dizziness and even headaches upon awakening! Thanks again.
My pleasure, Dr. Bartal.
“with symptoms of vertigo that was exacerbated by certain visual environments such as shopping malls, supermarkets with tall aisles, and in general all fluorescent lighting.”
This has been my nightmare for 5.5 years! I have been offered no diagnosis, and obviously no fix. I would go to the ends of the earth to get cured from this awful feeling. Please contact me with any help, information, or possible suggestions. Thank you.
I will email you personally on your case.
Like Craig, I also have been dealing with this same problem for several years now. I am otherwise a quite healthy and fit 44 year. The problem has gotten to the point where I cannot even have a standing conversation with someone ( I must sit down or feel unbalanced), nor can I enter a large dept store without a shopping cart to lean on. I have been thru an MRI, been tested by the Univ of Pennsylvania Balance Center, been to Physical rehab… All with no real change to my condition. I would love to hear more about the Vion therapy and the tinted glasses. (Sunglasses do seen to help some.)
Did you find what was wrong or a medication that can help you? I have the visual vertigo and feel like passing out in stores. Never had this start until last March 2012. Now I feel this dreamy feeling a lot. I thought I felt better over summer but it came back very badly in September. 😦 Any input would be very helpful. Thank you!!
I also have these exact same symptoms! I would love to know more about this therapy and the glasses.
I have had these symptoms since I had a head injury in 2007. I have had workups, MRIs, prism glasses, trifocals (nightmare, and not tinted), vestibular rehab, valium, etc. The only thing that’s helped at all is being on Acetazolamide – which I was put on by a neuro-opthalmologist a few years ago. At least now I can function most days. I would give anything to get rid of this. It’s an incredible problem to have – effects almost every part of my life. I am always trying to see if I can find anything new on the web that addresses it. This sounds interesting! Jean
I live in Oklahoma and am 36 iv had this bad for over a year I would do anything for a cure…It has caused me so much anxiety and fear I can’t go very many places….Please Help
Thank you for your comment. It is important for you to first have a comprehensive Neuro-optometric vision evaluation. I would encourage you to seek a doctor through the COVD website, Dr. Locator. Go to http://www.covd.org and click on Find a Doctor.
This is a great topic for vertigo. i so happiness.
I have experienced really weird unsteadiness in stores and elsewhere that seems to be related to visual orientation. Believe (in fact I am sure) that the statin drugs I take are causing this problem in my case. After reducing my statin drug to every other day there was a significant improvement in the condition. Tried going back on the statin every day and had a near pass out in a BJ store. Went back to every other day on the statin drug and I am almost back to near normal.