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Vision Challenges with Vestibular Disorders by the Vestibular Disorders Association

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Vision Challenges with Vestibular Disorders by the Vestibular Disorders Association PO BOX 13305 · PORTLAND, OR 97213 · FAX: (503) 229-8064 · (800) 837-8428 · [email protected] · WWW.VESTIBULAR.ORG Vision Challenges with Vestibular Disorders By the Vestibular Disorders Association A common complaint for people with held steady by the photographer (the vestibular disorders is that they have VOR) in order to produce clear pictures. difficulty with their vision. They have However, if the photographer is unable problems focusing on an object or to hold the camera steady, the resulting perceive that objects are moving from pictures will be blurry or perhaps have side to side or revolving around them double exposures, even though the (vertigo). They may see their visual field camera itself is in perfect working order. jiggle or bounce (oscillopsia) or have A malfunctioning vestibular system double vision (diplopia). When they hold changes the once skilled photographer their heads still, the problems disappear. into an unskilled one. People with a The optometrist, who conducts eye chronic vestibular disorder must learn to exams while a patient’s head is securely adapt to this newly unpredictable visual braced against a head rest, is often world—a challenge that only increases in unaware that a vestibular problem complexity if they also require glasses or exists. When the optometrist then other visual correction. explains the normal results of the exam, such patients may become disgruntled or How does the vestibulo-ocular reflex frustrated because the test results don’t work? reflect the symptoms that they When the head is motionless, the experience in the course of daily life. number of impulses transmitted from the vestibular organs on the right side is Why do vestibular disorders affect equal to the number of impulses from the vision? left side. When the head turns toward The vestibular system sends motor the right, the number of impulses control signals via the nervous system to transmitted through the nervous system the muscles of the eyes with an from the right ear increases and the automatic function called the vestibulo- number from the left ear decreases. The ocular reflex (VOR). The VOR is a crucial difference in impulses sent from each part of maintaining balance and clear side controls eye movements to stabilize vision, controlling eye positions so that the gaze during active head motions. when the head moves, gaze remains stable. Another way of explaining this is There is a predictable ratio between the to compare the vision system to photo- amount of head movement and the graphy. The camera (the eyes) must be amount of eye movement required for a © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 1 of 7 stable gaze. When the head rotates at a frequent head movements are required, certain angle and speed, the eyes rotate such as when a person converses with at the same speed (gain) but in the others at work or at a social gathering. opposite direction (phase). The sensory information provided by both ears is Reading text on a printed page presents normally symmetrical. Signals coming a special challenge for people with an from the left ear correspond with the impaired VOR. The bouncing and shifting information provided by the right ear. words and letters require more effort to Thus, if the vestibular organs in one or process (see Figure 1), which is why both ears are not working properly, the children with an undiagnosed vestibular brain receives conflicting signals about disorder are sometimes mistakenly movement, resulting in the sensation of thought to be dyslexic. vertigo. Impacts of a disrupted vestibulo- Try to read this ocular reflex May appear like this: A disrupted or impaired VOR can result Try to read thiis in abnormal nystagmus, an excessive Try to read this to-and-fro movement of the eyes, and oscillopsia, where objects appear to Figure 1. For people with oscillopsia, tracking printed words on a page can require bounce because they do not remain a great deal of effort because of the fixed on the same point on the retina. distortion produced by even small head A person with a vestibular disorder may movements. also experience photosensitivity (discomfort with bright light) and other Reading text on a computer monitor can vision problems such as: intense be even more problematic because of a discomfort with flickering lights, heightened sensitivity to screen flickering particularly fluorescent, sodium, or or scrolling pages of text. Many people mercury vapor lights; moving objects; with an impaired VOR resort to manually rows of similar objects, such as in bracing their head to reduce reading grocery store aisles or lines of text on a problems, such as by cupping their chin page; or busy, high contrast patterns, in their hand, in an effort to prevent tiny such as polka dots or sunlight filtering movements—even those as small as are through mini-blinds. Environments with produced by a pulse. a combination of fluorescent lighting and busy patterns or moving objects are People with vestibular disorders face especially problematic which is why particular challenges with peripheral shopping in large stores may be very vision, which works to integrate visual difficult. Even environments with information with vestibular functions and subdued décor can be fatiguing if is vital for maintaining a sense of balance © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 2 of 7 and orientation. A damaged VOR may called visual dependence, where the result in peripheral visual flickers that brain suppresses vestibular input and may be mistakenly perceived as becomes extremely reliant on vision to movement, such as the illusion of a bird maintain balance. However, because of flying quickly past. In addition, the impaired VOR, disorientation and nystagmus is more pronounced when a symptoms of panic can occur in person looks to the far right or left, so situations where movement of objects actions such as looking over the shoulder near the person may be mistaken for while backing up a car can be especially self-movement. These symptoms may uncomfortable. also occur when a person’s visual field is overwhelmed (e.g., in a room wallpaper- Peripheral vision distortions are especially ed with busy patterns) or lacks a point of problematic for a person who wears fixation (e.g., in intense darkness, wide glasses and has adapted to a vestibular open spaces, or as experienced with disorder by minimizing head movements snow blindness). and relying instead on moving the eyes. Although eyeglasses produce clear and Evaluation consistent vision straight ahead, lens The diagnosis of a vestibular disorder aberrations such as visual field curvature relies on a combination of careful and distortion reduce vision clarity when inspection of the history of the problem, a person looks through the side of a lens physical examination, and tests. Because (Figure 2). Thus, if a person with glasses vision is so closely linked to the vestibular moves the eyes rather than the head to system, many of these diagnostic tests scan, objects viewed to the side will involve evaluation of the gain, phase, appear to distort and move. Certain and symmetry of eye movements that shapes of windshields in cars or vans occur with vestibular stimulation. may cause similar peripheral distortion at their edges. Figure 2 (below). Projection of a flat object (A) onto a curved surface causes straight Ironically, a person with a vestibular lines to appear curved (B) as the power disorder may experience a phenomenon (curvature) of a lens increases, so does the A B C D © Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 3 of 7 correct farsightedness cause pincushion-type disorder is to treat the vestibular distortion (C) and glasses that correct disorder. Depending on the specific nearsightedness cause a barrel-like distortion vestibular disorder diagnosis, treatment (D). may involve surgery, physical therapy, medication, or other strategies. When a For example, electronystagmography chronic vestibular disorder does not (ENG) tests measure nystagmus that resolve with treatment, specialized occurs when the head is positioned in vestibular rehabilitation exercises may certain ways while a person tracks a still be useful in helping with the related moving object, or when the ear on one impacts on vision. Vestibular side is stimulated with warm or cold rehabilitation is an exercise-based water or air (the caloric test). During program that includes coordinating eye these tests, eye movements are recorded and head movements, stimulating the using small electrodes placed on the skin symptoms of dizziness in order to around the eyes or with an infrared video desensitize the vestibular system, camera mounted on goggles (known as improving balance and walking ability, videonystagmography or VNG). Rotation and improving fitness. testing employs the same electrodes or goggles to measure the relationship Optometric therapies may also be part between the speed of head movement of treatment—especially if an underlying and eye movements while the head is focusing, ocular alignment, visual acuity, rotated. or visual processing problem is suspected in addition to the VOR It is important to note that these and problem caused by the vestibular other tests employed to evaluate vision disorder. Such optometric rehabilitation and vestibular disorders must be treatment may involve the use of administered and interpreted by trained corrective lenses, including prisms and 1 specialists. Factors such as age, spectacles, phototherapy (light therapy), 2(p. 51) medications, or systemic processes and therapy to help sharpen vision skills 3 4 such as depression, migraine, or sleep or develop the eye muscles involved in 5,6 deprivation can modify the VOR. Such focusing, such as exercises that have a factors must be incorporated into the person cover one eye while reading. testing process and interpretation of the results by physicians such as otolaryn- Glasses and contact lenses gologists/ENTs, otologists, neurotologists, With glasses, the type of vision otoneurologists, and ophthalmologists.
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