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Visual Acuity While Walking and Oscillopsia Severity in Healthy Subjects and Patients with Unilateral and Bilateral Vestibular Function Loss

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Visual Acuity While Walking and Oscillopsia Severity in Healthy Subjects and Patients with Unilateral and Bilateral Vestibular Function Loss ORIGINAL ARTICLE Visual Acuity While Walking and Oscillopsia Severity in Healthy Subjects and Patients With Unilateral and Bilateral Vestibular Function Loss Nils Guinand, MD; Mark Pijnenburg, MSc; Maurice Janssen, PhD; Herman Kingma, PhD Objectives: To assess visual acuity (VA) while the pa- Main Outcome Measures: Differences in VA at 2, 4, tient is walking and to evaluate oscillopsia severity in pa- and 6 km/h and oscillopsia severity score. tients with bilateral vestibulopathy (BV) and in patients with unilateral vestibular loss (UVL). Results: As a group, patients with BV showed a signifi- cant increase of the VA differences compared with healthy Ͻ Ͻ Design: Prospective study with a group of patients with subjects (P .001) and patients with UVL (P .001) for BV, a group of patients with UVL, and a control group all 3 walking velocities. Normality thresholds were de- of healthy subjects. fined as healthy subjects’ 95% CI. Sensitivity of the test was 97% for discriminating patients with BV. Moderate to extreme oscillopsia severity was found in 81% of pa- Setting: Tertiary academic center. tients with BV and in 9% of patients with UVL. Differ- ences in VA did not correlate with oscillopsia severity Participants: Thirty seven patients with BV(age range, scores in patients with BV (PϾ.05 for all comparisons). 29-80 years), 11 patients with UVL (age range, 48-75 years), and 57 healthy subjects (age range 20-77 years). Conclusions: We designed a highly sensitive, simple, cost-effective protocol to assess dynamic VA under physi- Intervention: Computation of the difference between ologic conditions and a questionnaire to determine os- the VA measured in static conditions and in dynamic con- cillopsia severity. Both tools could be used for the evalu- ditions while walking on a treadmill at 2, 4, and 6 km/h. ation of new treatments for BV and patients with UVL. Oscillopsia severity was assessed with a questionnaire that we developed. Arch Otolaryngol Head Neck Surg. 2012;138(3):301-306 ALKING IS PROBABLY significantly impaired or absent. Thus, with the most common high-frequency head movements (Ͼ1 Hz), form of motion for the retinal slip cannot be optimally com- an active adult. pensated. Because the threshold for per- During moderately ception of retinal drift is close to 1°/s in Wfast walking (6 km/h), a combination of healthy subjects,2 high-frequency head vertical and horizontal translational and movements can lead to oscillopsia, an il- rotational head movements is induced. lusion of movement of the visual environ- Author Affiliations: Division of Vertical head translation occurs at the step- ment. For low-frequency head move- Balance Disorders, Department ping frequency (2 Hz), and lateral head ments (Ͻ1 Hz), the optokinetic reflex and, of Otorhinolaryngology, translation at the stride frequency (1 Hz). to a certain extent, the cervicoocular re- University Hospital Maastricht, Maastricht, the Netherlands Peak head pitch and yaw angular veloci- flex can generate compensatory eye move- 3 (Drs Guinand, Janssen, and ties are around 17°/s, which is in the func- ments. Efficient stabilization of the im- Kingma and Mr Pijnenburg); tional range of vestibuloocular reflex age on the retina is also necessary to Department of Otolaryngology (VOR).1 The induced image slip on the preserve visual acuity (VA) during head Head and Neck Surgery, retina is greatly compensated by the VOR, movements. Indeed, VA decreases rap- University Hospitals, Geneva, which generates compensatory eye move- idly when the retinal slip exceeds the Switzerland (Dr Guinand); and ments opposite to head movements. In threshold of few degrees per second Biomedical Engineering, 4 Eindhoven University of healthy subjects, a gain (eye velocity/ (2.5°/s-4.0°/s). Technology, Eindhoven, the head velocity) close to 1 allows efficient Illusory perception of motion and de- Netherlands (Mr Pijnenburg image stabilization on the retina. In with creased VA during head movements can and Drs Janssen and Kingma). bilateral vestibulopathy (BV), the VOR is be experienced simultaneously by pa- ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 138 (NO. 3), MAR 2012 WWW.ARCHOTO.COM 301 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tients with BV, and the combination is often described no standardized way of assessing oscillopsia severity. Both without distinction as “blurred vision,” one of the main the DVA protocol and the oscillopsia severity question- complaints of patients with BV, and can lead to a signifi- naire described herein should allow evaluation of treat- cant deterioration of quality of life.5 Although patients ments for patients with BV and patients with UVL. with BV have reported a certain subjective improve- 6 ment after vestibular rehabilitation, there is unfortu- METHODS nately no evidence of an efficient treatment. Zingler et al7 found that, independent of the etiology, in more than 80% of 82 patients with BV who had at least 3 months of TEST SUBJECTS vestibular training, there was neither a subjective im- provement in their condition nor an improvement in their Thirty-seven patients (20 men and 17 women; mean age, 56 years; age range, 29-80 years) with BV were observed at the Di- vestibular reflexes (follow-up range, 3 months to 13 years vision of Balance Disorders at Maastricht University Hospital after initial diagnosis). between January 2010 and May 2011. They all fulfilled 3 in- The idea of a vestibular implant that could provide clusion criteria: (1) mean peak slow phase velocity of 5°/s or the central nervous system with information about less in bilateral bithermal caloric irrigations; (2) pathologic HIT head angular velocities by electric stimulation of the for horizontal and vertical canals; and (3) a gain of 25% or less vestibular nerve has emerged. Recently, partial recovery on rotatory chair tests. Electronystagmography (ENG) was used of the VOR has been achieved by electric stimulation of for vestibular testing. Bilateral bithermal (30°C and 44°C) ca- the semicircular canals of labyrinthine-defective mon- loric irrigations with water were performed by experienced tech- keys.8-10 In humans, important steps toward the devel- nicians under standard conditions. Rotatory chair tests con- opment of a vestibular implant have been made. Surgi- sisted of horizontal torsion swing (0.1 Hz; maximum velocity, 100°/s) and bilateral velocity steps (velocity, 250°/s). Manual cal approaches to electrode implantation sites have 11,12 HITs were recorded with a high-speed camera (Casio Exilim, been described, and the first electric stimulations of Pro EX-F1; Casio) at 12ϫoptical zoom and 300 frames per sec- the vestibular nerve have shown that it is possible to ond in the 3 semicircular canal planes. Presence of corrective elicit controlled eye movements.13,14 saccades was considered pathologic. All recordings were ana- If VOR can be restored in humans, specific tests to se- lyzed by an experienced otorhinolaryngologist. All patients had lect and monitor vestibular implant candidates will be a normal neurologic status and normal oculomotor function. needed. Gaze stabilization can be tested with the Head A group of 11 patients (7 men and 4 women; mean age, 61 Impulse Test (HIT)15 in the 3 different semicircular ca- years; age range, 48-75 years) with UVL was also included. They nals planes. The presence of corrective ocular saccades all fulfilled the following criteria: (1) unilateral mean peak slow reveals an abnormal VOR function.16 Gaze stabilization phase velocity of 5°/s or less in bilateral bithermal caloric irri- gations; (2) unilateral pathologic HIT for horizontal and ver- performance can also be evaluated by measurement of tical canals; and (3) a gain of more than 30% for horizontal tor- the VA during active or passive, vertical and horizontal sion swing (0.11 Hz; maximum velocity, 100°/s). head movements; this process is called dynamic VA As a control group, 57 healthy subjects were included (32 (DVA).17 Passive high angular velocity (150°/s) move- men and 25 women; mean age, 41 years; age range, 20-77 of ments allow best discrimination between patients with years), who had no prior vestibular symptoms and normal HIT unilateral vestibular loss (UVL) or bilateral vestibular loss findings in the 3 semicircular canal planes. and normal subjects.18 A drawback of these approaches is the nonphysi- VA TESTING ologic stimuli that are applied. In the present study, we opted for VA measurements while the patient was walk- Visual acuity was measured in the 3 groups using a chart of ing on a treadmill at different velocities, which corre- Sloan letters (CDHKNORSVZ). The chart consisted of rows of sponds to physiologic stimuli. The fact that the test can- 5 randomly chosen letters. As for the standard Snellen chart not discriminate the side, in a case of unilateral vestibular used by ophthalmologists, VA decreased 0.1 log unit per row loss, is not relevant because we aim to select patients with on the logMAR scale. The VA scale was adapted to the test sub- bilateral impairment of the vestibular function. ject distance, which was 2.8 m for all measurements. The chart Visual acuity testing has already been investigated un- was positioned at eye height. Visual acuity was tested binocu- larly. Measurements were performed with eye corrections in der similar conditions, showing a significant DVA de- place for subjects who wore glasses or contact lenses. Measure- crease in patients with BV compared with healthy sub- ment procedures were identical in static and dynamic condi- 19,20 jects. The correlation between DVA and oscillopsia tions. The experimental setup was calibrated and validated by severity was not assessed. For horizontal movements, it comparison with the known VA (determined at the depart- was shown that oscillopsia severity is most likely re- ment of ophthalmology) in 10 healthy subjects.
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