Ocular counterrolling as an indicator of vestibular otolith function

Trunk Instability in the Pitch, Yaw, and Roll Planes during Clinical Balance Tests: Axis Differences and Correlations to vHIT Asymmetries Following Acute Unilateral Vestibular Loss

BACKGROUND

Clinical dynamic posturography concentrates on the pitch and roll but not on the yaw plane instability measures. This emphasis may not represent the axis instability observed in clinical stance and gait tasks for patients with balance deficits in comparison to healthy control (HC) subjects, nor the expected instability based on correlations with vestibulo-ocular reflex (VOR) deficits. To examine the axis stability changes with vestibular loss, we measured trunk sway in all three directions (pitch, roll, and yaw) during the stance and gait tasks of patients with acute unilateral vestibular neuritis (aUVN) and compared the results with those of HC. Concurrent changes in VORs were also examined and correlated with trunk balance deficits.

METHODS

The results of 11 patients (mean age of 61 years) recorded within 6 days of aUVN onset were compared within those of 8 age-matched healthy controls (HCs). All subjects performed a two-legged stance task-standing with eyes closed on foam (s2ecf), a semi-gait task-walking eight tandem steps (tan8), and four gait tasks-walking 3 m with head rotating laterally, pitching, or eyes closed (w3hr, w3hp, w3ec), and walking over four barriers 24 cm high, spaced 1 m apart (barr). The tasks' peak-to-peak yaw, pitch and roll angles, and angular velocities were measured with a gyroscope system (SwayStarTM) mounted at L1-3 and combined into three, axis-specific, balance control indexes (BCI), using angles (a) for the tandem gait and barriers task, and angular velocities (v) for all other tasks, as follows: axis BCI = (2 × 2ecf)v + 1.5 × (w3hr + w3hp + w3ec)v + (tan8 + 12 × barr)a.

RESULTS

Yaw and pitch BCIs were significantly (p ≤ 0.004) greater (88 and 30%, respectively) than roll BCIs for aUVN patients. For HCs, only yaw but not pitch BCIs were greater (p = 0.002) than those of roll (72%). The order of BCI aUVN vs. HC differences was pitch, yaw, and roll at 55, 44, and 31%, respectively (p ≤ 0.002). This difference with respect to roll corresponded to the known greater yaw plane than roll plane asymmetry (40 vs. 22%) following aUVN based on VOR responses. However, the lower pitch plane asymmetry (3.5%) in VOR responses did not correspond with the pitch plane instability observed in the balance control tests. The increases in pitch plane instability in UVL subjects were, however, highly correlated with those of roll and yaw.

CONCLUSIONS

These results indicate that greater yaw than pitch and roll trunk motion during clinical balance tasks is common for aUVN patients and HCs. However, aUVN leads to a larger increase in pitch than yaw plane instability and a smaller increase in roll plane instability. This difference with respect to roll corresponds to the known greater yaw plane than roll plane asymmetry (40 vs. 22%) following aUVN observed in VOR responses. However, the lower pitch plane asymmetry (3.5%) in VOR responses does not correspond with the enhanced movements in the pitch plane, observed in balance control tasks. Whether asymmetries in vestibular-evoked myogenic potentials (Vemps) are better correlated with the deficits in pitch plane balance control remains to be investigated. The current results provide a strong rationale for the clinical testing of directional specific balance responses, especially yaw and pitch, and the linking of balance results for yaw and roll to VOR asymmetries.

Temporal dynamics of ocular torsion and vertical vergence during visual, vestibular, and visuovestibular rotations

Ocular torsion and vertical divergence reflect the brain's sensorimotor integration of motion through the vestibulo-ocular reflex (VOR) and the optokinetic reflex (OKR) to roll rotations. Torsion and vergence however express different response patterns depending on several motion variables, but research on their temporal dynamics remains limited. This study investigated the onset times of ocular torsion (OT) and vertical vergence (VV) during visual, vestibular, and visuovestibular motion, as well as their relative decay rates following prolonged optokinetic stimulations. Temporal characteristics were retrieved from three separate investigations where the level of visual clutter and acceleration were controlled. Video eye-tracking was used to retrieve the eye-movement parameters from a total of 41 healthy participants across all trials. Ocular torsion consistently initiated earlier than vertical vergence, particularly evident under intensified visual information density, and higher clutter levels were associated with more balanced decay rates. Additionally, stimulation modality and accelerations affected the onsets of both eye movements, with visuovestibular motion triggering earlier responses compared to vestibular motion, and increased accelerations leading to earlier onsets for both movements. The present study showed that joint visuovestibular responses produced more rapid onsets, indicating a synergetic sensorimotor process. It also showed that visual content acted as a fusional force during the decay period, and imposed greater influence over the torsional onset compared to vergence. Acceleration, by contrast, did not affect the temporal relationship between the two eye movements. Altogether, these findings provide insights into the sensorimotor integration of the vestibulo-ocular and optokinetic reflex arcs.

Video Ocular Counter-Roll (vOCR): Otolith-Ocular Function and Compensatory Effect of the Neck Following Vestibular Loss

OBJECTIVE

Assessment of recovery following vestibular loss has been limited by the lack of bedside measures in clinical settings. Here, we used the video ocular counter-roll (vOCR) test to study otolith-ocular function and compensatory effect of neck proprioception in patients at different stages of vestibular loss.

STUDY DESIGN

Case-control study.

SETTING

Tertiary care center.

METHODS

Fifty-six subjects were recruited including patients with acute (9 ± 2 days [mean ± standard error of mean]), subacute (61 ± 11 days), and chronic (1009 ± 266 days) unilateral loss of vestibular function, as well as a group of healthy controls. We used a video-oculography method based on tracking the iris for vOCR measurement. To examine the effect of neck inputs, vOCR was recorded during two simple tilt maneuvers in all subjects while seated: 30° head-on-body tilt and 30° head-and-body tilt.

RESULTS

The vOCR responses evolved at different stages following vestibular loss with improvement of the gains in the chronic stage. The deficit was more pronounced when the whole body was tilted (acute: 0.08 ± 0.01, subacute: 0.11 ± 0.01, chronic: 0.13 ± 0.02, healthy control: 0.18 ± 0.01), and the gain of vOCR improved when the head was tilted on the body (acute: 0.11 ± 0.01, subacute: 0.14 ± 0.01, chronic: 0.13 ± 0.02, healthy control: 0.17 ± 0.01). The time course of vOCR response was affected as well with reduced amplitude and slower response in the acute stage of vestibular loss.

CONCLUSION

The vOCR test can be valuable as a clinical marker to measure vestibular recovery and compensatory effect of neck proprioception in patients at different stages following loss of vestibular function.

Deep Learning Model for Static Ocular Torsion Detection Using Synthetically Generated Fundus Images

Purpose

The objective of the study is to develop deep learning models using synthetic fundus images to assess the direction (intorsion versus extorsion) and amount (physiologic versus pathologic) of static ocular torsion. Static ocular torsion assessment is an important clinical tool for classifying vertical ocular misalignment; however, current methods are time-intensive with steep learning curves for frontline providers.

Methods

We used a dataset (n = 276) of right eye fundus images. The disc-foveal angle was calculated using ImageJ to generate synthetic images via image rotation. Using synthetic datasets (n = 12,740 images per model) and transfer learning (the reuse of a pretrained deep learning model on a new task), we developed a binary classifier (intorsion versus extorsion) and a multiclass classifier (physiologic versus pathologic intorsion and extorsion). Model performance was evaluated on unseen synthetic and nonsynthetic data.

Results

On the synthetic dataset, the binary classifier had an accuracy and area under the receiver operating characteristic curve (AUROC) of 0.92 and 0.98, respectively, whereas the multiclass classifier had an accuracy and AUROC of 0.77 and 0.94, respectively. The binary classifier generalized well on the nonsynthetic data (accuracy = 0.94; AUROC = 1.00).

Conclusions

The direction of static ocular torsion can be detected from synthetic fundus images using deep learning methods, which is key to differentiate between vestibular misalignment (skew deviation) and ocular muscle misalignment (superior oblique palsies).

Translational Relevance

Given the robust performance of our models on real fundus images, similar strategies can be adopted for deep learning research in rare neuro-ophthalmologic diseases with limited datasets.

Adaptive perceptual responses to asymmetric rotation for testing otolithic function

This study aimed to test the role of the otolithic system in self-motion perception by examining adaptive responses to asymmetric off-axis vertical rotation. Self-movement perception was examined after a conditioning procedure consisting of prolonged asymmetric sinusoidal yaw rotation of the head on a stationary body with hemicycle faster than the other hemicycle. This asymmetric velocity rotation results in a cumulative error in spatial self-motion perception in the upright position that persists over time. Head yaw rotation conditioning was performed in different head positions: in the upright position to activate semicircular canals and in the supine and prone positions to activate both semicircular canals and otoliths with the phase of otolithic stimulation reversed with respect to activation of the semicircular canals. The asymmetric conditioning influenced the cumulative error induced by four asymmetric cycles of whole-body vertical axis yaw rotation. The magnitude of this error depended on the orientation of the head during the conditioning. The error increased by 50% after upright position conditioning, by 100% in the supine position, and decreased by 30% in the prone position. The enhancement and reduction of the perceptual error are attributed to otolithic modulation because of gravity influence of the otoliths during the conditioning procedure in supine and prone positions. These findings indicate that asymmetric velocity otolithic activation induces adaptive perceptual errors such as those induced by semicircular canals alone, and this adaptation may be useful in testing dynamic otolithic perceptual responses under different conditions of vestibular dysfunction.

The Role of Different Afferent Systems in the Modulation of the Otolith-Ocular Reflex After Long-Term Space Flights

Background

The vestibular (otolith) function is highly suppressed during space flight (SF) and the study of these changes is very important for the safety of the space crew during SF missions. The vestibular function (particularly, otolith-ocular reflex–OOcR) in clinical and space medicine is studied using different methodologies. However, different methods and methodologies can influence the outcome results.

Objective

The current study addresses the question of whether the OOcR results obtained by different methods are different, and what the role is of the different afferent systems in the modulation of the OOcR.

Methods

A total of 25 Russian cosmonauts voluntarily took part in our study. They are crewmembers of long duration space missions on the International Space Station (ISS). Cosmonauts were examined in pre- and post-flight “Sensory Adaptation” and “Gaze Spin” experiments, twice before (preflight) and three times after SF (post-flight). We used two different video oculography (VOG) systems for the recording of the OOcR obtained in each experiment.

Results

Comparison of the two VOG systems didn’t result into significant and systematic differences in the OOcR measurements. Analysis of the static torsion otolith–ocular reflex (OOR), static torsion otolith–cervical–ocular reflex (OCOR) and static torsion otolith–ocular reflex during eccentric centrifugation (OOREC) shows that the OOREC results in a lower OOcR response compared to the OOR and OCOR (before flight and late post-flight). However, all OOcRs were significantly decreased in all cosmonauts early post-flight.

Conclusion

Analysis of the results of ocular counter rolling (OCR) obtained by different methods (OOR, OCOR, and OOREC) showed that different afferent systems (tactile-proprioception, neck-cervical, visual and vestibular afferent input) have an impact on the OOcR.

Bilateral Asymmetry in Ocular Counter-Rolling Reflex Is Associated With Individual Motion Sickness Susceptibility

Accumulating evidence suggests that individual variations in vestibular functions are associated with motion sickness (MS) susceptibility. We investigated whether vestibular functions in the reflex and cortical pathways could predict the susceptibility of individuals to MS. MS-susceptible and control adults were recruited according to the Motion Sickness Susceptibility Questionnaire (MSSQ) score. Otolith reflex and cortical functions were assessed using the ocular counter rolling test and the head-tilt subjective visual vertical (HT-SVV) test, respectively. The bilateral asymmetry of each function was compared between the MS-susceptible and the control groups. Although the two tests for otolith functions were conducted using the same stimulation (lateral head tilt), bilateral asymmetry of otolith reflex rather than cortical function was significantly associated with MS susceptibility. Our data suggests that bilateral asymmetry in the otolith reflex pathway is capable of predicting susceptibility to MS to some extent. Our data also suggest that the association between vestibular function and MS susceptibility can vary based on the vehicle types. Future vehicles, such as self-driving cars, will make us aware of other vestibular functions associated with MS susceptibility.

Evaluation of the Video Ocular Counter-Roll (vOCR) as a New Clinical Test of Otolith Function in Peripheral Vestibulopathy

Importance

Video-oculography (VOG) goggles have been integrated into the assessment of semicircular canal function in patients with vestibular disorders. However, a similar bedside VOG method for testing otolith function is lacking.

Objective

To evaluate the use of VOG-based measurement of ocular counter-roll (vOCR) as a clinical test of otolith function.

Design, Setting, and Participants

A case-control study was conducted to compare vOCR measurement among patients at various stages of unilateral loss of vestibular function with healthy controls. The receiver operating characteristic curve method was used to determine the diagnostic accuracy of the vOCR test in detecting loss of otolith function. Participants were recruited at a tertiary center including the Johns Hopkins outpatient clinic and Johns Hopkins Hospital, Baltimore, Maryland. Participants included 56 individuals with acute (≤4 weeks after surgery), subacute (4 weeks-6 months after surgery), and chronic (>6 months after surgery) unilateral vestibular loss as well as healthy controls. A simple bedside maneuver with en bloc, 30° lateral tilt of the head and trunk was used for vOCR measurement. The study was conducted from February 2, 2017, to March 10, 2019.

Intervention

In each participant vOCR was measured during static tilts of the head and trunk en bloc.

Main Outcomes and Measures

The vOCR measurements and diagnostic accuracy of vOCR in detecting patients with loss of vestibular function from healthy controls.

Results

Of the 56 participants, 28 (50.0%) were men; mean (SD) age was 53.5 (11.4) years. The mean (SD) time of acute unilateral vestibular loss was 9 (7) days (range, 2-17 days) in the acute group, 61 (39) days (range, 28-172 days) in the subacute group, and 985 (1066) days (range 185-4200 days) in the chronic group. The vOCR test showed reduction on the side of vestibular loss, and the deficit was greater in patients with acute and subacute vestibular loss than in patients with chronic loss and healthy controls (acute vs chronic: -1.81°; 95% CI, -3.45° to -0.17°; acute vs control: -3.18°; 95% CI, -4.83° to -1.54°; subacute vs chronic: -0.63°; 95% CI, -2.28° to 1.01°; subacute vs control: -2.01°; 95% CI, -3.65° to -0.36°; acute vs subacute: -1.17°; 95% CI, -2.88° to 0.52°; and chronic vs control: -1.37°; 95% CI, -2.96° to 0.21°). The asymmetry in vOCR between the side of vestibular loss and healthy side was significantly higher in patients with acute vs chronic loss (0.28; 95% CI, 0.06-0.51). Overall, the performance of the vOCR test in discriminating between patients with vestibular loss and healthy controls was 0.83 (area under the receiver operating characteristic curve). The best vOCR threshold to detect vestibular loss at the 30° tilt was 4.5°, with a sensitivity of 80% (95% CI, 0.62%-0.88%) and specificity of 82% (95% CI, 0.57%-1.00%).

Conclusions and Relevance

The findings of this case-control study suggest that the vOCR test can be performed with a simple bedside maneuver and may be used to detect or track loss of otolith function.

The Anatomical and Physiological Basis of Clinical Tests of Otolith Function. A Tribute to Yoshio Uchino

Otolithic receptors are stimulated by gravitoinertial force (GIF) acting on the otoconia resulting in deflections of the hair bundles of otolithic receptor hair cells. The GIF is the sum of gravitational force and the inertial force due to linear acceleration. The usual clinical and experimental tests of otolith function have used GIFs (roll tilts re gravity or linear accelerations) as test stimuli. However, the opposite polarization of receptors across each otolithic macula is puzzling since a GIF directed across the otolith macula will excite receptors on one side of the line of polarity reversal (LPR at the striola) and simultaneously act to silence receptors on the opposite side of the LPR. It would seem the two neural signals from the one otolith macula should cancel. In fact, Uchino showed that instead of canceling, the simultaneous stimulation of the oppositely polarized hair cells enhances the otolithic response to GIF—both in the saccular macula and the utricular macula. For the utricular system there is also commissural inhibitory interaction between the utricular maculae in each ear. The results are that the one GIF stimulus will cause direct excitation of utricular receptors in the activated sector in one ear as well as indirect excitation resulting from the disfacilitation of utricular receptors in the corresponding sector on the opposite labyrinth. There are effectively two complementary parallel otolithic afferent systems—the sustained system concerned with signaling low frequency GIF stimuli such as roll head tilts and the transient system which is activated by sound and vibration. Clinical tests of the sustained otolith system—such as ocular counterrolling to roll-tilt or tests using linear translation—do not show unilateral otolithic loss reliably, whereas tests of transient otolith function [vestibular evoked myogenic potentials (VEMPs) to brief sound and vibration stimuli] do show unilateral otolithic loss. The opposing sectors of the maculae also explain the results of galvanic vestibular stimulation (GVS) where bilateral mastoid galvanic stimulation causes ocular torsion position similar to the otolithic response to GIF. However, GVS stimulates canal afferents as well as otolithic afferents so the eye movement response is complex.

Investigating short latency subcortical vestibular projections in humans: what have we learned?

Vestibular evoked myogenic potentials (VEMPs) are now widely used for the noninvasive assessment of vestibular function and diagnosis in humans. This review focuses on the origin, properties, and mechanisms of cervical VEMPs and ocular VEMPs; how these reflexes relate to reports of vestibular projections to brain stem and cervical targets; and the physiological role of (otolithic) cervical and ocular reflexes. The evidence suggests that both VEMPs are likely to represent the effects of excitation of irregularly firing otolith afferents. While the air-conducted cervical VEMP appears to mainly arise from excitation of saccular receptors, the ocular VEMP evoked by bone-conducted stimulation, including impulsive bone-conducted stimuli, mainly arises from utricular afferents. The surface responses are generated by brief changes in motor unit firing. The effects that have been demonstrated are likely to represent otolith-dependent vestibulocollic and vestibulo-ocular reflexes, both linear and torsional. These observations add to previous reports of short latency otolith projections to the target muscles in the neck (sternocleidomastoid and splenius) and extraocular muscles (the inferior oblique). New insights have been provided by the investigation and application of these techniques.

Use of iris pattern recognition to evaluate ocular torsional changes associated with head tilt

Purpose

To describe the use of enhanced iris images and a computer software program to quantify ocular torsional changes associated with head tilt.

Methods

Pixel coordinates of the pupil and different iris landmarks were obtained manually using paint program from digital images of the right and left iris of 3 subjects with normal extraocular motility. Photographs of the right eye and of the left eye were taken in the straight-ahead position and at various degrees of right and left head tilt. A computer software program converted the x- and y-pixel coordinates into angles of rotation after averaging multiple points and determining the degree and the direction of torsion for each eye. The degree of head tilt was mathematically calculated from the digital images. The degree and the direction of ocular torsion were correlated with the degree and the direction of head tilt.

Results

The average degree of head tilt was 27.5 degrees (from 8 to 43 degrees). The average intorsion of the lower eye per degree of head tilt was 0.61 degrees (from 0.54 to 0.65 degrees). The average extorsion of the higher eye per degree of head tilt was 0.56 degrees (from 0.43 to 0.60 degrees). The average ocular torsional changes strongly correlated with the degree of head tilt (correlation coefficient = 0.92).

Conclusions

Computer-assisted iris pattern recognition and analysis of the ocular torsional changes associated with head tilt may provide a useful and objective means of assessing ocular torsion.

The Contributions of Vestibular Evoked Myogenic Potentials and Acoustic Vestibular Stimulation to Our Understanding of the Vestibular System

Vestibular-evoked myogenic potentials (VEMPs) are short-latency muscle reflexes typically recorded from the neck or eye muscles with surface electrodes. They are used clinically to assess otolith function, but are also interesting as they can provide information about the vestibular system and its activation by sound and vibration. Since the introduction of VEMPs more than 25 years ago, VEMPs have inspired animal and human research on the effects of acoustic vestibular stimulation on the vestibular organs, their projections and the postural muscles involved in vestibular reflexes. Using a combination of recording techniques, including single motor unit recordings, VEMP studies have enhanced our understanding of the excitability changes underlying the sound-evoked vestibulo-collic and vestibulo-ocular reflexes. Studies in patients with diseases of the vestibular system, such as superior canal dehiscence and Meniere's disease, have shown how acoustic vestibular stimulation is affected by physical changes in the vestibule, and how sound-evoked reflexes can detect these changes and their resolution in clinical contexts. This review outlines the advances in our understanding of the vestibular system that have occurred following the renewed interest in sound and vibration as a result of the VEMP.

Ocular Counter Rolling in Astronauts After Short- and Long-Duration Spaceflight

Ocular counter-rolling (OCR) is a reflex generated by the activation of the gravity sensors in the inner ear that stabilizes gaze and posture during head tilt. We compared the OCR measures that were obtained in 6 astronauts before, during, and after a spaceflight lasting 4-6 days with the OCR measures obtained from 6 astronauts before and after a spaceflight lasting 4-9 months. OCR in the short-duration fliers was measured using the afterimage method during head tilt at 15°, 30°, and 45°. OCR in the long-duration fliers was measured using video-oculography during whole body tilt at 25°. A control group of 7 subjects was used to compare OCR measures during head tilt and whole body tilt. No OCR occurred during head tilt in microgravity, and the response returned to normal within 2 hours of return from short-duration spaceflight. However, the amplitude of OCR was reduced for several days after return from long-duration spaceflight. This decrease in amplitude was not accompanied by changes in the asymmetry of OCR between right and left head tilt. These results indicate that the adaptation  of otolith-driven reflexes to microgravity is a long-duration process.

Effects of Optokinetic Stimulation on Verticality Perception Are Much Larger for Vision-Based Paradigms Than for Vision-Independent Paradigms

Introduction

Verticality perception as assessed by the subjective visual vertical (SVV) is significantly biased by a rotating optokinetic stimulus. The underlying mechanisms of this effect remain open. Potentially, the optokinetic stimulus induces a shift of the internal estimate of the direction of gravity. This hypothesis predicts a shift of perceived vertical using other, non-vision dependent, paradigms as well. Alternatively, an optokinetic stimulus may only induce a shift of visual orientation, and so would be task specific.

Methods

To test this prediction, both vision-dependent SVV and vision-independent [subjective haptic vertical (SHV)] paradigms were applied. In 12 healthy human subjects, perceived vertical was measured in different whole-body roll positions (up to ±120°, steps = 30°) while watching a clockwise or counterclockwise rotating optokinetic stimulus. For comparison, baseline trials were collected in darkness. A generalized linear model was applied for statistical analysis.

Results

A significant main effect for optokinetic stimulation was noted both for the SVV paradigm (p < 0.001) and the SHV paradigm (p = 0.013). However, while pairwise comparisons demonstrated significant optokinetic-induced shifts (p ≤ 0.035) compared to baseline in all roll-tilted orientations except 30° and 60° left-ear-down position and counterclockwise optokinetic stimulation for the SVV paradigm, significant shifts were found in only 1 of the 18 test conditions (120° left-ear-down roll orientation, counterclockwise optokinetic stimulation) for the SHV paradigm. Compared to the SHV, the SVV showed significantly (p < 0.001) larger shifts of perceived vertical when presenting a clockwise (15.3 ± 16.0° vs. 1.1 ± 5.2°, mean ± 1 SD) or counterclockwise (−12.6 ± 7.7° vs. −2.6 ± 5.4°) rotating optokinetic stimulus.

Conclusion

Comparing the effect of optokinetic stimulation on verticality perception in both vision-dependent and vision-independent paradigms, we demonstrated distinct patterns. While significant large and roll-angle dependent shifts were noted for the SVV, offsets were minor and reached significance only in one test condition for the SHV. These results suggest that optokinetic stimulation predominately affects vision-related mechanisms, possibly due to induced torsional eye displacements, and that any shifts of the internal estimate of the direction of gravity are relatively minor.

Whole-Body Roll Tilt Influences Goal-Directed Upper Limb Movements through the Perceptual Tilt of Egocentric Reference Frame

In our day-to-day life, we can accurately reach for an object in our gravitational environment without any effort. This can be achieved even when the body is tilted relative to gravity. This is accomplished by the central nervous system (CNS) compensation for gravitational forces and torque acting on the upper limbs, based on the magnitude of body tilt. The present study investigated how performance of upper limb movements was influenced by the alteration of body orientation relative to gravity. We observed the spatial trajectory of the index finger while the upper limb reached for a memorized target with the body tilted in roll plane. Results showed that the terminal location of the fingertip shifted toward the direction of body tilt away from the actual target location. The subsequent experiment examined if the perceived direction of the body longitudinal axis shifted relative to the true direction in roll plane. The results showed that the perceived direction of the body longitudinal axis shifted toward the direction of the body tilt, which correlated with the shift of the terminal location in the first experiment. These results suggest that the dissociation between the egocentric and gravitational coordinates induced by whole-body tilt leads to systematic shifts of the egocentric reference frame for action, which in turn influences the motor performance of goal-directed upper limb movements.

The video ocular counter-roll (vOCR): a clinical test to detect loss of otolith-ocular function

CONCLUSION

vOCR can detect loss of otolith-ocular function without specifying the side of vestibular loss. Since vOCR is measured with a simple head tilt maneuver, it can be potentially used as a bedside clinical test in combination with video head impulse test.

OBJECTIVE

Video-oculography (VOG) goggles are being integrated into the bedside assessment of patients with vestibular disorders. Lacking, however, is a method to evaluate otolith function. This study validated a VOG test for loss of otolith function.

METHODS

VOG was used to measure ocular counter-roll (vOCR) in 12 healthy controls, 14 patients with unilateral vestibular loss (UVL), and six patients with bilateral vestibular loss (BVL) with a static lateral head tilt of 30°. The results were compared with vestibular evoked myogenic potentials (VEMP), a widely-used laboratory test of otolith function.

RESULTS

The average vOCR for healthy controls (4.6°) was significantly different from UVL (2.7°) and BVL (1.6°) patients (p < 0.0001). The vOCR and VEMP measurements were correlated across subjects, especially the click and tap oVEMPs (click oVEMP R = 0.45, tap oVEMP R = 0.51; p < 0.0003). The receiver operator characteristic (ROC) analysis showed that vOCR and VEMPs detected loss of otolith function equally well. The best threshold for vOCR to detect vestibular loss was at 3°. The vOCR values from the side of vestibular loss and the healthy side were not different in UVL patients (2.53° vs 2.8°; p = 0.59).

Sustained and Transient Vestibular Systems: A Physiological Basis for Interpreting Vestibular Function

Otolithic afferents with regular resting discharge respond to gravity or low-frequency linear accelerations, and we term these the static or sustained otolithic system. However, in the otolithic sense organs, there is anatomical differentiation across the maculae and corresponding physiological differentiation. A specialized band of receptors called the striola consists of mainly type I receptors whose hair bundles are weakly tethered to the overlying otolithic membrane. The afferent neurons, which form calyx synapses on type I striolar receptors, have irregular resting discharge and have low thresholds to high frequency (e.g., 500 Hz) bone-conducted vibration and air-conducted sound. High-frequency sound and vibration likely causes fluid displacement which deflects the weakly tethered hair bundles of the very fast type I receptors. Irregular vestibular afferents show phase locking, similar to cochlear afferents, up to stimulus frequencies of kilohertz. We term these irregular afferents the transient system signaling dynamic otolithic stimulation. A 500-Hz vibration preferentially activates the otolith irregular afferents, since regular afferents are not activated at intensities used in clinical testing, whereas irregular afferents have low thresholds. We show how this sustained and transient distinction applies at the vestibular nuclei. The two systems have differential responses to vibration and sound, to ototoxic antibiotics, to galvanic stimulation, and to natural linear acceleration, and such differential sensitivity allows probing of the two systems. A 500-Hz vibration that selectively activates irregular otolithic afferents results in stimulus-locked eye movements in animals and humans. The preparatory myogenic potentials for these eye movements are measured in the new clinical test of otolith function—ocular vestibular-evoked myogenic potentials. We suggest 500-Hz vibration may identify the contribution of the transient system to vestibular controlled responses, such as vestibulo-ocular, vestibulo-spinal, and vestibulo-sympathetic responses. The prospect of particular treatments targeting one or the other of the transient or sustained systems is now being realized in the clinic by the use of intratympanic gentamicin which preferentially attacks type I receptors. We suggest that it is valuable to view vestibular responses by this sustained-transient distinction.

Clinical measurement of compensatory torsional eye movement during head tilt

PURPOSE

To measure the degree of compensatory torsional eye movement during head tilt using a fundus photography method.

METHODS

We enrolled 55 healthy subjects who were 20-66 years of age. Fundus photographs were obtained in the presumed baseline position and in stepwise head tilt positions to evaluate ocular torsion using a non-mydriatic fundus camera. Horizontal marks on the nose were photographed simultaneously to evaluate head tilt. Images were analysed using Photoshop to measure the degree of ocular torsion and head tilt.

RESULTS

A consistent compensatory torsional eye movement was observed in all subjects during head tilt. The degree of compensatory torsional eye movement showed a positive correlation with the angle of head tilt. Ocular torsional disconjugacy was observed during head tilt, with larger excycloductional eye movement than incycloductional eye movement (4.88 ± 2.91° versus 4.50 ± 2.76°, p < 0.001). In multiple linear regression analysis, the degree of compensatory torsional eye movement was significantly associated with the degree of head tilt (β = 0.191, p < 0.001), and the direction of cycloduction (β = -0.548, p < 0.001).

CONCLUSIONS

The fundus photography method is a non-invasive, accurate and objective tool for measuring compensatory torsional eye movement. Considering the availability of fundus photography in clinical ophthalmology practice, the proposed method can be used as a clinical tool to measure compensatory torsional eye movement.

Ocular Reflex Phase during Off-Vertical Axis Rotation in Humans is Modified by Head-Turn-On-Trunk Position

Constant velocity Off-Vertical Axis Rotation (OVAR) imposes a continuously varying orientation of the head and body relative to gravity, which generates a modulation of horizontal (conjugate and vergence), vertical, and torsional eye movements. We introduced the head-turn-on-trunk paradigm during OVAR to examine the extent to whether the modulation of these ocular reflexes is mediated by graviceptors in the head, i.e., otoliths, versus other body graviceptors. Ten human subjects were rotated in darkness about their longitudinal axis 20° off-vertical at a constant velocity of 45 and 180°/s, corresponding to 0.125 and 0.5 Hz. Binocular responses were obtained with the head and trunk aligned, and then with the head turned relative to the trunk 40° to the right or left of center. The modulation of vertical and torsional eye position was greater at 0.125 Hz while the modulation of horizontal and vergence slow phase velocity was greater at 0.5 Hz. The amplitude modulation was not significantly altered by head-on-trunk position, but the phases shifted towards alignment with the head. These results are consistent with the modulation of ocular reflexes during OVAR being primarily mediated by the otoliths in response to the sinusoidally varying linear acceleration along the interaural and naso-occipital head axis.

Gravity dependence of the effect of optokinetic stimulation on the subjective visual vertical

Accurate and precise estimates of direction of gravity are essential for spatial orientation. According to Bayesian theory, multisensory vestibular, visual, and proprioceptive input is centrally integrated in a weighted fashion based on the reliability of the component sensory signals. For otolithic input, a decreasing signal-to-noise ratio was demonstrated with increasing roll angle. We hypothesized that the weights of vestibular (otolithic) and extravestibular (visual/proprioceptive) sensors are roll-angle dependent and predicted an increased weight of extravestibular cues with increasing roll angle, potentially following the Bayesian hypothesis. To probe this concept, the subjective visual vertical (SVV) was assessed in different roll positions (≤ ± 120°, steps = 30°, n = 10) with/without presenting an optokinetic stimulus (velocity = ± 60°/s). The optokinetic stimulus biased the SVV toward the direction of stimulus rotation for roll angles ≥ ± 30° (P < 0.005). Offsets grew from 3.9 ± 1.8° (upright) to 22.1 ± 11.8° (±120° roll tilt, P < 0.001). Trial-to-trial variability increased with roll angle, demonstrating a nonsignificant increase when providing optokinetic stimulation. Variability and optokinetic bias were correlated (R² = 0.71, slope = 0.71, 95% confidence interval = 0.57-0.86). An optimal-observer model combining an optokinetic bias with vestibular input reproduced measured errors closely. These findings support the hypothesis of a weighted multisensory integration when estimating direction of gravity with optokinetic stimulation. Visual input was weighted more when vestibular input became less reliable, i.e., at larger roll-tilt angles. However, according to Bayesian theory, the variability of combined cues is always lower than the variability of each source cue. If the observed increase in variability, although nonsignificant, is true, either it must depend on an additional source of variability, added after SVV computation, or it would conflict with the Bayesian hypothesis.NEW & NOTEWORTHY Applying a rotating optokinetic stimulus while recording the subjective visual vertical in different whole body roll angles, we noted the optokinetic-induced bias to correlate with the roll angle. These findings allow the hypothesis that the established optimal weighting of single-sensory cues depending on their reliability to estimate direction of gravity could be extended to a bias caused by visual self-motion stimuli.

The new vestibular stimuli: sound and vibration-anatomical, physiological and clinical evidence

The classical view of the otoliths-as flat plates of fairly uniform receptors activated by linear acceleration dragging on otoconia and so deflecting the receptor hair bundles-has been replaced by new anatomical and physiological evidence which shows that the maculae are much more complex. There is anatomical spatial differentiation across the macula in terms of receptor types, hair bundle heights, stiffness and attachment to the overlying otolithic membrane. This anatomical spatial differentiation corresponds to the neural spatial differentiation of response dynamics from the receptors and afferents from different regions of the otolithic maculae. Specifically, receptors in a specialized band of cells, the striola, are predominantly type I receptors, with short, stiff hair bundles and looser attachment to the overlying otoconial membrane than extrastriolar receptors. At the striola the hair bundles project into holes in the otolithic membrane, allowing for fluid displacement to deflect the hair bundles and activate the cell. This review shows the anatomical and physiological evidence supporting the hypothesis that fluid displacement, generated by sound or vibration, deflects the short stiff hair bundles of type I receptors at the striola, resulting in neural activation of the irregular afferents innervating them. So these afferents are activated by sound or vibration and show phase-locking to individual cycles of the sound or vibration stimulus up to frequencies above 2000 Hz, underpinning the use of sound and vibration for clinical tests of vestibular function.

Upright Perception and Ocular Torsion Change Independently during Head Tilt

We maintain a stable perception of the visual world despite continuous movements of our eyes, head and body. Perception of upright is a key aspect of such orientation constancy. Here we investigated whether changes in upright perception during sustained head tilt were related to simultaneous changes in torsional position of the eyes. We used a subjective visual vertical (SVV) task, modified to track changes in upright perception over time, and a custom video method to measure ocular torsion simultaneously. We tested 12 subjects in upright position, during prolonged (~15 min) lateral head tilts of 20 degrees, and also after the head returned to upright position. While the head was tilted, SVV drifted in the same direction as the head tilt (left tilt: -5.4 ± 1.4° and right tilt: +2.2 ± 2.1°). After the head returned to upright position, there was an SVV aftereffect with respect to the pre-tilt baseline, which was also in the same direction as the head tilt (left tilt: -3.9 ± 0.6° and right tilt: +2.55 ± 1.0°). Neither the SVV drift nor the SVV aftereffect were correlated with the changes in ocular torsion. Using the Bayesian spatial-perception model we show that the pattern of SVV drift and aftereffect in our results could be explained by a drift and an adaptation in sensory inputs that encode head orientation. The fact that ocular torsion (mainly driven by the otoliths) could not account for the perceptual changes suggests that neck proprioception could be the primary source of drift in upright perception during head tilt, and subsequently the aftereffect in upright position.

Bedside evaluation of dizzy patients

In recent decades there has been marked progress in the imaging and laboratory evaluation of dizzy patients. However, detailed history taking and comprehensive bedside neurotological evaluation remain crucial for a diagnosis of dizziness. Bedside neurotological evaluation should include examinations for ocular alignment, spontaneous and gaze-evoked nystagmus, the vestibulo-ocular reflex, saccades, smooth pursuit, and balance. In patients with acute spontaneous vertigo, negative head impulse test, direction-changing nystagmus, and skew deviation mostly indicate central vestibular disorders. In contrast, patients with unilateral peripheral deafferentation invariably have a positive head impulse test and mixed horizontal-torsional nystagmus beating away from the lesion side. Since suppression by visual fixation is the rule in peripheral nystagmus and is frequent even in central nystagmus, removal of visual fixation using Frenzel glasses is required for the proper evaluation of central as well as peripheral nystagmus. Head-shaking, cranial vibration, hyperventilation, pressure to the external auditory canal, and loud sounds may disclose underlying vestibular dysfunction by inducing nystagmus or modulating the spontaneous nystagmus. In patients with positional vertigo, the diagnosis can be made by determining patterns of the nystagmus induced during various positional maneuvers that include straight head hanging, the Dix-Hallpike maneuver, supine head roll, and head turning and bending while sitting. Abnormal smooth pursuit and saccades, and severe imbalance also indicate central pathologies. Physicians should be familiar with bedside neurotological examinations and be aware of the clinical implications of the findings when evaluating dizzy patients.

Modulation of internal estimates of gravity during and after prolonged roll-tilts

Perceived direction of gravity, as assessed by the subjective visual vertical (SVV), shows roll-angle dependent errors that drift over time and a bias upon return to upright. According to Bayesian observer theory, the estimated direction of gravity is derived from the posterior probability distribution by combining sensory input and prior knowledge about earth-vertical in a statistically optimal fashion. Here we aimed to further characterize the stability of SVV during and after prolonged roll-tilts. Specifically we asked whether the post-tilt bias is related to the drift pattern while roll-tilted. Twenty-nine healthy human subjects (23-56 yo) repetitively adjusted a luminous arrow to the SVV over periods of 5 min while upright, roll-tilted (± 45°, ± 90°), and immediately after returning to upright. Significant (p<0.05) drifts (median absolute drift-amplitude: 10°/5 min) were found in 71% (± 45°) and 78% (± 90°) of runs. At ± 90° roll-tilt significant increases in absolute adjustment errors were more likely (76%), whereas significant increases (56%) and decreases (44%) were about equally frequent at ± 45°. When returning to upright, an initial bias towards the previous roll-position followed by significant exponential decay (median time-constant: 71 sec) was noted in 47% of all runs (all subjects pooled). No significant correlations were found between the drift pattern during and immediately after prolonged roll-tilt. We conclude that the SVV is not stable during and after prolonged roll-tilt and that the direction and magnitude of drift are individually distinct and roll-angle-dependent. Likely sensory and central adaptation and random-walk processes contribute to drift while roll-tilted. Lack of correlation between the drift and the post-tilt bias suggests that it is not the inaccuracy of the SVV estimate while tilted that determines post-tilt bias, but rather the previous head-roll orientation relative to gravity. We therefore favor central adaptation, most likely a shift in prior knowledge towards the previous roll orientation, to explain the post-tilt bias.

Optokinetic stimulation can break Listing's law without induction of eye movement

OBJECTIVE

Pseudo-images of three-dimensional eye movements captured on an infrared video oculogram can be translated onto a rotational expression around axial vector. This provides a subject's Listing's plane, which moves according to the head's orientation relative to gravity. Optokinetically induced changes in the cognitive gravitational reference frame will affect the context of Listing's plane. The purpose of this study was to estimate the effect of OKS on Listing's plane.

METHODS

In this study, we presented vertical optokinetic visual stimulation with fixation targets, which are thought to induce pseudo-inclination of the head, and evaluated changes in the subjects' Listing's plane.

RESULTS

We observed no stimulus-induced movement of Listing's plane that corresponded to the assumed pseudo-recognition of a change in verticality. On the other hand, we did observe vergence movement of Listing's plane (in the yaw plane), which corresponded to exposure to diminished and increased gravitational circumstance. In addition, the thickness of Listing's plane significantly increased with the load of each stimulation.

CONCLUSION

Vertical OKS leads to a rotation of Listing's plane mainly around a vertical axis. This may represent false exhibition of central compensatory re-weighting with respect to inherent otoconial mass asymmetry resulting from the OKS-mediated loss of the gravity reference. In addition, a OKS-mediated thickening of Listing's plane suggests to us that confusing visual input can reduce the stability of the internal model, which would likely manifest itself as a thickening of Listing's plane. In other words, fluctuation between the build-up and drop-out of vection induced by optokinetic stimulation will cause a thickening of Listing's plane. The thickness of Listing's plane could be a novel clinical parameter for quantitatively evaluating static vestibular function and accuracy of the internal model.

Egocentric and allocentric alignment tasks are affected by otolith input

Gravicentric visual alignments become less precise when the head is roll-tilted relative to gravity, which is most likely due to decreasing otolith sensitivity. To align a luminous line with the perceived gravity vector (gravicentric task) or the perceived body-longitudinal axis (egocentric task), the roll orientation of the line on the retina and the torsional position of the eyes relative to the head must be integrated to obtain the line orientation relative to the head. Whether otolith input contributes to egocentric tasks and whether the modulation of variability is restricted to vision-dependent paradigms is unknown. In nine subjects we compared precision and accuracy of gravicentric and egocentric alignments in various roll positions (upright, 45°, and 75° right-ear down) using a luminous line (visual paradigm) in darkness. Trial-to-trial variability doubled for both egocentric and gravicentric alignments when roll-tilted. Two mechanisms might explain the roll-angle–dependent modulation in egocentric tasks: 1) Modulating variability in estimated ocular torsion, which reflects the roll-dependent precision of otolith signals, affects the precision of estimating the line orientation relative to the head; this hypothesis predicts that variability modulation is restricted to vision-dependent alignments. 2) Estimated body-longitudinal reflects the roll-dependent variability of perceived earth-vertical. Gravicentric cues are thereby integrated regardless of the task's reference frame. To test the two hypotheses the visual paradigm was repeated using a rod instead (haptic paradigm). As with the visual paradigm, precision significantly decreased with increasing head roll for both tasks. These findings propose that the CNS integrates input coded in a gravicentric frame to solve egocentric tasks. In analogy to gravicentric tasks, where trial-to-trial variability is mainly influenced by the properties of the otolith afferents, egocentric tasks may also integrate otolith input. Such a shared mechanism for both paradigms and frames of reference is supported by the significantly correlated trial-to-trial variabilities.

Single motor unit activity in human extraocular muscles during the vestibulo-ocular reflex

Motor unit activity in human eye muscles during the vestibulo-ocular reflex (VOR) is not well understood, since the associated head and eye movements normally preclude single unit recordings. Therefore we recorded single motor unit activity following bursts of skull vibration and sound, two vestibular otolith stimuli that elicit only small head and eye movements. Inferior oblique (IO) and inferior rectus (IR) muscle activity was measured in healthy humans with concentric needle electrodes. Vibration elicited highly synchronous, short-latency bursts of motor unit activity in the IO (latency: 10.5 ms) and IR (14.5 ms) muscles. The activation patterns of the two muscles were similar, but reciprocal, with delayed activation of the IR muscle. Sound produced short-latency excitation of the IO muscle (13.3 ms) in the eye contralateral to the stimulus. Simultaneous needle and surface recordings identified the IO as the muscle of origin of the vestibular evoked myogenic potential (oVEMP) thus validating the physiological basis of this recently developed clinical test of otolith function. Single extraocular motor unit recordings provide a window into neural activity in humans that can normally only be examined using animal models and help identify the pathways of the translational VOR from otoliths to individual eye muscles.

Changes in Listing plane thickness caused by vestibular schwannoma: a parameter for evaluating the accuracy of the gravity-oriented internal model

OBJECTIVE

Three-dimensional analysis of video-oculograms can be used to calculate Listing plane for patients and experimental subjects. Listing plane reflects the head's orientation with respect to gravity, which suggests that the plane is derived from otolithic vestibular input, itself, or from a gravity-oriented internal model constructed through integration of visual, vestibular, and proprioceptive sensory inputs. The goal of this study was to determine whether the Listing plane can serve as a parameter for evaluating static (peripheral or central) vestibular function.

STUDY DESIGN

Prospective study.

SETTING

Tertiary referral center.

PATIENTS

Healthy subjects and patients with unilateral vestibular schwannoma without any previous treatment.

INTERVENTION

Diagnostic.

MAIN OUTCOME MEASURES

Video-oculograms were recorded from healthy subjects (aged 36.8 ± 6.3 yr) and from patients (aged 60.3 ± 7.5 yr) during voluntary gaze with the head in an upright or each-side-down orientation, and the thicknesses of the calculated Listing planes were then compared.

RESULTS

Results revealed thickening of the Listing plane in patients only when the head was in an impaired-side-down orientation (1.250 ± 0.795 and 1.074 ± 0.759 degrees in the right- and left-side-down head orientations in healthy subjects versus 2.222 ± 1.237 degrees in the impaired-side-down orientation in patients), and this thickening correlated with caloric weakness. By contrast, neither the sensation of postural instability nor postural disturbance in force platform recordings contributed to the thickness of Listing plane.

CONCLUSION

The thickness of the Listing plane could be a novel parameter for quantitatively evaluating static vestibular (otolithic) function, although central compensation might exist.

Differences between otolith- and semicircular canal-activated neural circuitry in the vestibular system

In the last two decades, we have focused on establishing a reliable technique for focal stimulation of vestibular receptors to evaluate neural connectivity. Here, we summarize the vestibular-related neuronal circuits for the vestibulo-ocular reflex, vestibulocollic reflex, and vestibulospinal reflex arcs. The focal stimulating technique also uncovered some hidden neural mechanisms. In the otolith system, we identified two hidden neural mechanisms that enhance otolith receptor sensitivity. The first is commissural inhibition, which boosts sensitivity by incorporating inputs from bilateral otolith receptors, the existence of which was in contradiction to the classical understanding of the otolith system but was observed in the utricular system. The second mechanism, cross-striolar inhibition, intensifies the sensitivity of inputs from both sides of receptive cells across the striola in a single otolith sensor. This was an entirely novel finding and is typically observed in the saccular system. We discuss the possible functional meaning of commissural and cross-striolar inhibition. Finally, our focal stimulating technique was applied to elucidate the different constructions of axonal projections from each vestibular receptor to the spinal cord. We also discuss the possible function of the unique neural connectivity observed in each vestibular receptor system.

Effects of head-down bed rest and artificial gravity on spatial orientation

We studied spatial orientation before and after 21 days of 6 degrees head-down bed rest in 15 subjects. During bed rest, 8 subjects were treated daily with 1 h Gz centrifugation (artificial gravity) (2.5 g at the feet; 1.0 g at the heart), with 7 subjects serving as controls. Ocular counter-rolling and subjective visual vertical were assessed during 90 degrees whole body roll tilt to the left and right. Ocular counter-rolling was unaffected by bed rest and bed rest + artificial gravity. Performance on the subjective visual vertical task was unchanged in the control group, but exhibited a significant increase in error for 48 h after bed rest in the treatment (artificial gravity) group. Intermittent application of linear acceleration along the long body axis may have increased the weighting of the idiotropic vector, resulting in an increased bias of the subjective visual vertical toward the long body axis during 90 degrees roll tilt.

Frequency-dependent spatiotemporal tuning properties of non-eye movement related vestibular neurons to three-dimensional translations in squirrel monkeys

Responses of vestibular-only translation sensitive (VOTS) neurons in vestibular nuclei of two squirrel monkeys were studied at multiple frequencies to three-dimensional translations and rotations. A novel frequency-dependent spatiotemporal analysis examined in each neuron whether complex models, with unrestricted response dynamics in three-dimensional (3D) space, provided significantly better fits than restricted models following simple, cosine rule. Subsequently, the statistically selected optimal model was used to predict the maximum translation direction, expressed as a unitary vector, Vt(max), and its associated sensitivity and phase across frequencies. Simple models were sufficient to quantify the 3D translational responses of 66% of neurons. Most VOTS neurons, complex or simple, exhibited flat-gain or low-pass response dynamics. The Vt(max) of simple neurons was fixed, whereas that of complex neurons changed with frequency. The spatial distribution of Vt(max) in simple neurons, which fell within 30 degrees of either the horizontal plane or/and the sagittal plane, was closely aligned with Vt(max) of vestibular afferents. In contrast, the frequency-dependent Vt(max) of most complex neurons migrated from the dorsoventral axis at higher frequency toward the horizontal plane, especially the interaural axis, at lower frequency. When the maximum rotation direction was estimated from responses of the same VOTS neurons to 1.2 Hz yaw, pitch, and roll rotations, complex neurons were more likely to respond to rotations activating vertical canals. Responses to 0.15-0.3 Hz linear accelerations produced by inertial or gravitational forces were indistinguishable in most complex neurons but significantly different in most simple neurons. These observations suggest that simple and complex VOTS neurons constitute distinctive vestibular pathways where complex neurons, exhibiting a novel spatiotemporal filtering mechanism in processing otolith-related signals, are well suited to drive tilt-related responses, whereas simple neurons probably mediate pure translation related responses.

Gravity Dependence of Subjective Visual Vertical Variability

The brain integrates sensory input from the otolith organs, the semicircular canals, and the somatosensory and visual systems to determine self-orientation relative to gravity. Only the otoliths directly sense the gravito-inertial force vector and therefore provide the major input for perceiving static head-roll relative to gravity, as measured by the subjective visual vertical (SVV). Intraindividual SVV variability increases with head roll, which suggests that the effectiveness of the otolith signal is roll-angle dependent. We asked whether SVV variability reflects the spatial distribution of the otolithic sensors and the otolith-derived acceleration estimate. Subjects were placed in different roll orientations (0–360°, 15° steps) and asked to align an arrow with perceived vertical. Variability was minimal in upright, increased with head-roll peaking around 120–135°, and decreased to intermediate values at 180°. Otolith-dependent variability was modeled by taking into consideration the nonuniform distribution of the otolith afferents and their nonlinear firing rate. The otolith-derived estimate was combined with an internal bias shifting the estimated gravity-vector toward the body-longitudinal. Assuming an efficient otolith estimator at all roll angles, peak variability of the model matched our data; however, modeled variability in upside-down and upright positions was very similar, which is at odds with our findings. By decreasing the effectiveness of the otolith estimator with increasing roll, simulated variability matched our experimental findings better. We suggest that modulations of SVV precision in the roll plane are related to the properties of the otolith sensors and to central computational mechanisms that are not optimally tuned for roll-angles distant from upright.

Vestibular evoked myogenic potentials evoked by brief interaural head acceleration: properties and possible origin

The vestibular system responds to head acceleration by producing compensatory reflexes in the eyes and postural muscles. In this study, we investigated the effect of brief interaural acceleration on the vestibular evoked myogenic potential (VEMP) in 10 normal subjects and 10 patients with bilateral (bVL) or unilateral vestibular loss (uVL). The stimuli were delivered with a handheld minishaker and tendon hammer over the mastoid and produced relatively pure interaural head acceleration with little rotation (mean peak acceleration: 0.14 g at 3.3 ms). VEMPs were recorded from the neck muscles and were characterized in normal subjects by a positive/negative potential ipsilateral to the stimulated side (peak latencies: 15.1 and 22.6 ms) and a positive response contralaterally (20.3 ms), which was sometimes preceded by a negativity (14.5 ms). These peaks were absent in patients with bVL, confirming their vestibular dependence. In the patients with uVL, medial acceleration of the intact ear produced bilateral responses, an initial positivity on the intact side, and a negativity on the affected side, whereas lateral acceleration produced only a late positivity on the intact side. As the acceleration was primarily in the horizontal plane, it is likely to have activated utricular receptors. Consistent with this, we found that VEMPs are very sensitive to the direction of head acceleration and have features consistent with the utriculocollic projections demonstrated in animals.

Loss of otolith function with age is associated with increased postural sway measures

Loss of balance and increased fall risk is a common problem associated with aging. Changes in vestibular function occur with aging but the contribution of reduced vestibular otolith function to fall risk remains unknown. We examined a population of 151 healthy individuals (aged 21-93) for both balance (sway measures) and ocular counter-rolling (OCR) function. We assessed balance function with eyes open and closed on a firm surface, eyes open and closed on a foam surface and OCR during +/-20 degree roll tilt at 0.005 Hz. Subjects demonstrated a significant age-related reduction in OCR and increase in postural sway. The effect of age on OCR was greater in females than males. The reduction in OCR was strongly correlated with the mediolateral measures of sway with eyes closed. This correlation was also present in the elderly group alone, suggesting that aging alone does not account for this effect. OCR decreased linearly with age and at a greater rate in females than males. This loss of vestibular otolith-ocular function is associated with increased mediolateral measures of sway which have been shown to be related to increased risk of falls. These data suggest a role for loss of otolith function in contributing to fall risk in the elderly. Further prospective, longitudinal studies are necessary to confirm these findings.

Drift in Ocular Torsion during Sustained Head Tilt

PURPOSE

A head tilt towards the shoulder (roll) induces an ocular counter-roll (OCR), i.e. torsion in the opposite direction to the head. How this counter-rolled position is maintained during a static head tilt is in debate. In a previous study, we reported an OCR-increasing drift subsequent to the head tilt. This finding is in contrast to other reports where no such response was found. The primary aim of this study was to repeat the experiment during a prolonged head-tilt test and to describe the OCR characteristics. A secondary aim was to investigate the influence of spatial visual cues on OCR.

METHODS

Five male subjects performed a head tilt (30 degrees ) towards the right shoulder while the eye position was recorded during a 10-minute interval. In test 1, the subjects viewed a target with no cues for spatial orientation. The same head-tilt paradigm was repeated in test 2 with a visual target with spatial cues. Two samples of data were extracted from the start and the end of the recordings for statistical analysis.

RESULTS

Subsequent to the head tilt, a slow OCR-increasing drift in the opposite direction to the head roll was found in all subjects. On average, this drift lasted for 30 sec (+/- 5) in test 1 and for 55 sec (+/- 18) in test 2. The drift was then found to change its direction, i.e. the eyes were rotated in the same direction as the head roll. When measured after 10 minutes, the OCR was significantly decreased.

CONCLUSIONS

The OCR during static head tilt is not constant. During the first minute there is a gradually increasing OCR. Thereafter, the amplitude of the OCR decreases gradually. These changes are influenced to some extent by spatial visual cues. Possible mechanisms are adaptive responses in otolithic afferents as well as central nervous memory functions related to the semicircular canal system.

Subjective visual vertical during eccentric rotation in patients with benign paroxysmal positional vertigo

OBJECTIVE

There have been only a few reports of subjective visual vertical (SVV) in patients with benign paroxysmal positional vertigo (BPPV), and each showed slightly different results. SVV measurement during eccentric rotation that stimulated only 1 labyrinth was known to show a considerable improvement in comparison with conventional SVV as a clinical measure of otolith function. But there has not been a report regarding SVV during eccentric rotation in patients with BPPV. We therefore measured SVV during eccentric rotation and investigated the function of utricles in patients with BPPV.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS

Twenty-three patients with BPPV.

INTERVENTION

Diagnostic procedure.

MAIN OUTCOME MEASURES

SVV was measured in 23 patients with BPPV and 20 normal subjects. We compared the SVV values before and during eccentric rotation toward the right and left in both patients with BPPV and the control group.

RESULTS

Between BPPV patients and the control group, no difference in the SVV value was observed in pre-eccentric rotation, but significant differences of SVV values were found during eccentric rotation.

CONCLUSION

We identified utricular dysfunction in patients with BPPV during eccentric rotation and suggested that eccentric rotation might be a good method to measure utricular dysfunction.

Vestibular syndrome: a change in internal spatial representation

The vestibular system contributes to a wide range of functions from reflexes to spatial representation. This paper reviews behavioral, perceptive, and cognitive data that highlight the role of changes in internal spatial representation on the vestibular syndrome. Firstly, we review how visual vertical perception and postural orientation depend on multiple reference frames and multisensory integration and how reference frames are selected according to the status of the peripheral vestibular system (i.e., unilateral or bilateral hyporeflexia), the environmental constraints (i.e., sensory cues), and the postural constraints (i.e., balance control). We show how changes in reference frames are able to modify vestibular lesion-induced postural and locomotor deficits and propose that fast changes in reference frame may be considered as fast-adaptive processes after vestibular loss. Secondly, we review data dealing with the influence of vestibular loss on higher levels of internal representation sustaining spatial orientation and navigation. Particular emphasis is placed on spatial performance according to task complexity (i.e., the required level of spatial knowledge) and to the sensory cues available to define the position and orientation within the environment (i.e., real navigation in darkness or visual virtual navigation without any actual self-motion). We suggest that vestibular signals are necessary for other sensory cues to be properly integrated and that vestibular cues are involved in extrapersonal space representation. In this respect, vestibular-induced changes would be based on a dynamic mental representation of space that is continuously updated and that supports fast-adaptive processes.

[Function disorders of otoliths: clinical aspects and therapy options]

In the clinical routine, the diagnostic of the lateral gait is often comparable with a complete peripheral vestibular function examination. Diseases of the otolithic organs, with the saccule and utricle are not identified with conventional clinical examination methods. In more than 50% of patients with thermal hypostimulation, orientation tests show a simultaneous pathology of the utricle function. Participation of the saccule has been described for vestibular neuropathy, Menière's disease, bilateral vestibulopathy and acoustic neurinoma. Both otolithic organs are included in posttraumatic vertigo, a recognition, which will influence expert opinions in the future. Only by an exact diagnostic of diseases of the otolithic organs can individual disease courses be differential diagnostically separated from each other.

Ocular vestibular evoked myogenic potentials (OVEMPs) produced by impulsive transmastoid accelerations

OBJECTIVE

Recent work has demonstrated the existence of ocular vestibular evoked myogenic potentials (OVEMPs), which likely reflect projections underlying the translational vestibular ocular reflex (TVOR). We examined extraocular muscle activity associated with impulsive acceleration of the head in the transmastoid plane.

METHODS

Accelerometry was measured in 4 subjects in response to acceleration impulses produced by a gamma function delivered with a Minishaker (4810, Bruel & Kjaer). This stimulus produced peak head accelerations of 0.13-0.14 g occurring at between 3.1 and 4.0 ms at the mastoids for both right and left head movement. OVEMPs were recorded in 10 normal subjects with 5 directions of gaze, using electrode pairs placed lateral to, above and below the eyes.

RESULTS

OVEMPs occurred at short latency, with initial peaks between 10.3 ms (p10) and 15.3 ms (n15). For a given recording site and gaze direction, the responses were determined solely by the direction of imposed acceleration.

CONCLUSIONS

We propose that, given the transtemporal nature of the stimuli, utricular afferents are likely to be powerfully activated. The OVEMPs evoked may be generated by the lateral recti and oblique muscles.

SIGNIFICANCE

Sudden lateral accelerations of the head evoke the translational VOR and ocular counter rolling reflex and the pattern of muscle activations indicated by the OVEMPs appear to be a manifestation of these reflexes.