Midterm Ocular Motility Testing Flashcards by Sabrina Garza

Vestibular tests are a test of ____

Vestibular tests are tests of function

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What is the purpose of vestibular testing?

The purpose of vestibular testing is to determine if a symptom is caused by the inner ear (peripheral), by the brain (central) or mixed or other

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Pre Test instructions

when possible refrain from medication use for at least 12 hours
Don’t eat big meal prior to testing
wear comfortable clothing
Remove eye makeup prior

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Abbreviated Vestib Case History

Description
Timing
Frequency
Provoking Factors
Associated symptoms
medical history
medications

DTF PAMM

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Abbreviated Vestib Case History

Description

describe what you’re feeling (why are you here?)
Open - ended. Don’t lead or bias
Differentiate Vertigo VS Non- vertigo **

Vertigo typically peripheral

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Abbreviated Vestib Case History

Timing

How long does it last
is it continious
Short (sec,min) , intermediate (min - hrs) or long (>24 hrs)

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Abbreviated Vestib Case History

Frequency

how often

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Abbreviated Vestib Case History

Provoking

When do youo attacks occur
with what?
Change in head, neck, position, headaches, movement, loud noises, ear pressure, diet, visual stimuli, stress etc.

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Abbreviated Vestib Case History

Associted Symptoms

Hearing loss
tinnitus
aural fullness
pain
headache
Visual disturance
facial or motor weakness
autonomic symptoms (nausea, sweating)

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Abbreviated Vestib Case History

Medical History

Neuropathy (diabetes)
Vascular disease (stroke, heart disease)
Motion Sickness
Migraines
seizures
ear surgerys
Psychiatric Disease (anxxiety,depression & panic)
Other
famioly history
progression
severity level

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Abbreviated Vestib Case History

Medications

IV antibiotics, radiation therapy, chemo
Anti axiety, Diuretics
alcohol or durg use

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ENG/VNG Battery

Oculomotor exam
* Calibration
* spontaneous
* Gaze
* saccades
* Pursuit
* Optokinetic
Positioning exam
* Dix Hallpike
* Static Positional (supine)
Caloric irriagtions
* right warm
* left warm
* right cool
* left cool

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vestibular assessment

Ocular motility tests

Spontaneous (center gaze)
Gaze (horizontal, vertical)
saccades
Pursuit (horizontal, vertical)
Optokinetic
VOR
vergence is not perfomed

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vestibular assessment

Postional Maintence (gaze holding)

Center (aka spontaneous), left, right , up, down
Performed with & without fixation
requires multiple systems

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Present Center gaze/sponatneous =

Center gaze/sponatneous = non-localizing

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Present Eccentric gaze
Right,left,up & down

Eccentric gaze
Right,left,up & down
* Central
* Unless center gaze = non local

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Saccades

Primarily volitional, gets the fovea to target, fastest movements
* Saccadic eye movements are voluntary (you control them), and their purpose is to move the fovea (the center of sharp vision) to a new target. These movements are extremely fast compared to other types of eye movements (like smooth pursuit or vergence).

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Saccades parameters for interpretation

Velocity - speed of eye movement
Latency - how long after target moves does eye move
Accuracy - does the eye reach teh target
- undershoot
- overshoot

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for saccades what is the normative range?

normative range denoted by white area shaded is abnormal. Abnormal should be consistenly abnormla >50% of recording

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what is the saccadic accuracy abnormaility

Saccadic hypometria (undershoots)

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what is the saccadic accuracy abnormaility

Saccadic hypermetria (overshoots)

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Vestibular assessment

Pursuit tracking

Movement of the eyes while tacking an object
correlates with OPK
Involves ipsilateral cerebellar hemisphere, brain stem, or pariero - occiptal region

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what the parameters for pursuit interpretaion

Gain: eye movement relatiev to target movement
Phase: Rightward versus leftward
S: Some systems include # of saccades

GPS

Vestibular Assessment

Optokinetic (OPK/OKN)

occurs when you track a moving visual scene
Unlike smooth pursuit, the OKR involves tracking a moving field
Combination response slow phase: The eyes track the movement of the field.
Fast phase: The eyes make quick jumps (saccades) to reset position and catch up with the moving field.
Weakest subtest in ocular motility battery
Should involve movement in both central and peripheral visual fields

OPK Parameters for Interpretation

**Symmetry = rightward versus leftward** * Gain normative values exist but less sensitive due to numerous different stimuli and parameters * failure to increase eye speed would denote central abnormality

VOR

* Not a distinct subtest of ENG/VNG * Indirectly measured via caloric irrigation * Can be evaluated bedside by Halmagyi Head Thrust / Head Impulse Test

Normal & Abnormal VOR

Normal VOR = eyes remain on target, Abnormal VOR = eyes slip off target and must make corrective saccade back

VOR is useful for

Useful in detecting unilateral or bilateral peripheral hypofunction. Abnormal to side with corrective saccade

# ENG Test Battery What's included in eng test battery?

Positioning Test * The Dix-Hallpike Maneuver * The Side-Lying (DH) Maneuver

The most common cause of vertigo in the elderly.

BPPV

Caused by canalithiasis or cupulolithiasis of the posterior SCC (or anterior SCC).

BPPV

Assumed to be the result of displaced otoconia from the utricle settling in the posterior SCC (or anterior SCC).

BPPV

BPPV criteria

1. **Latency** Delayed onset of vertigo and nystagmus begin 1 or more seconds after the head is tilted toward the affected ear, and increase in severity to a maximum. 2. **Duration** less than 1 minute. Nystagmus reduces gradually after 10 to 40 seconds 3. **Linear-rotary nystagmus**. The nystagmus is linear-rotary with the fast phase beating toward the undermost ear or upward when the patient’s gaze is directed toward the uppermost ear. 4. **Reversal**. When the patient returns to the seated position, the vertigo and the nystagmus may reoccur in the opposite direction and less violently. 5. **Fatigability**. Constant repetition of this maneuver will result in ever lessening symptoms.

# BPPV Latency

Vertigo & nystagmus begin 1 or more seconds after the head is tilted toward the affected ear, and incrase in severity. - delayed latence

# BPPV Duration

Duration is less than 1 minute - nystagmus reduces graudally after 10 to 40 seconds and ultimately will stop

# BPPV Linear - rotary nystgamus

The nystsgamus is rotary with geotropic or ageotropic

# BPPV Reversal

when the patient returns to the seated position, the vertigo and the nystagmus may reoccur in opposite direction and less velocity

# BPPV Fatigability

Constant repetition of this manuver will result in ever lessening symptoms.

Positonal Testing procedure

* supine head center * Supine head turned right * supine head turned left * whole body left * repeats eye open & closed for left and right side 30 seconds in each position

Positional nystgamus is pathological if

1. it changes direction in any head position OR 2. It is persistent in at least 3 head positions OR 3. It is intermittent in all head positions OR 4. Its slow phase velocity exceed. 5 ENG deg/sec in any head position

# BPPV name the positonal tests

Dynamic - Dix-hallpike manuver Static - Supine head roll

what do Dix - hallpike and supine head roll assess?

Dix hallpike - BPPV in AC/PC Supine - BPPV in HC - Looks for any asymmetry in vestibular system

Otoconia freely moving in the endolypmph within in SCC. - Delayed onset & Fatigues over time - Geotopic in HC

Canalithiasis

Otoconia adhered to the cupula within the SCC or on the opposite side of the cupula. - immediate onset - little/no fatigue - ageotropic

Cupulolithiasis

Canalithiasis

Otoconia freely moving in the endolypmph within in SCC. - Delayed onset & Fatigues over time - Geotopic in HC

cupulolithiasis

Otoconia adhered to the cupula within the SCC or on the opposite side of the cupula. - immediate onset - little/no fatigue - ageotropic

BPPV Incidence

* Posterior C BPPV - Most common 90-95% * Horizontal canal 2nd MC 2 - 10% * Anterior Rare 1-3 %

Dix - hallpike maneuver

assess for AC/PC BPPV abnormaility = torsional nystgamus w/subjetive report (vertigo)

Positional Tests (supine head roll)

* Assess HC BPPV * abnormality = linear geotriopic or ageotropic

Treatment for BPPV

Habituation Techniques particle repositiong surgical Intervention

Anterior/Posterior BPPV treamnt

**Epley**: Most common for AC/PC canalithiasis bppv **Semont**: Most common for P/C & **cupulolithiasis**, A/C & P/C

Horizontal BPPV treatment

BBQ Roll: treats HC BPPV - geotropic

# Pursuits Impairment in both directions → Impairment in one direction →

Impairment in both directions → central Impairment in one direction → usually same sided lesion (stroke on R side → good left tracking, poor right) - always central

# Peripheral or central Saccades

Central

# Peripheral or central Optokinetic (OKN)

Optokinetic nystagmus (OKN) abnormalities are generally of central origin.