Ocular And Vestibular Assessments

Allowing a patient to hold gaze or fixate on something. Removing fixation is done either by wearing goggles or testing in a dark room. This is essential for vestibular testing

Slow, tracking movements of the eyes on an object
Completed with fixation

Normal: Should see smooth movements
Dysfunction:
• Saccadic intrusion: jumpiness or jerky eye movements

Both eyes working together to track an object moving toward the face (convergence) or away from the face (divergence)

Normal: Should see smooth movements, one eye may turn inward more than the other as an object comes close
Dysfunction: Convergence insufficiency, Convergence spasm/excess, orDivergence impairment

diplopia occurs >5 cm from the nose

vergence occurs during other tasks

difficulty pulling eyes apart to focus on a distance target

Ability to focus on an object up-close

Commonly impaired in patients >30 years of age
Normal: Ability to read 15 cm away from corneal plane
Gaze holding & nystagmus Description

Dysfunction:
• Nystagmus at rest
• Nystagmus with smooth pursuits

one direction nystagmus and indicates peripheral involvement

direction changing nystagmus and indicates central involvement

o Grade 1: unidirectional toward fast phase
o Grade 2: Spontaneous and nystagmus toward the fast phase side
o Grade 3: Nystagmus in all direction, strongest when gazing toward fast phase side

• Cover: One eye is covered and tester observes how the uncover eye moves. The misalignment is named for the opposite movement
• Uncover: When the eye is uncovered, tester observes what the eye moves. Eye will move to the center to refocus on the target. The misalignment is named for the opposite movement
Any vertical diplopia or vertical misalignment is a central sign and requires immediate medical work up

outward

inward

upward

downward

Testing of peripheral vision with eyes forward

Normal:
• 180 degrees in the horizontal plane
• 135 degrees in the vertical plane

Optic nerve testing (sensory aspect)
Autonomic reflex that constricts the pupil in response to light to limit light passing to retina

Normal:
• Equal and reactive

Vestibular ocular reflex that allows the head to move while eyes remain stable/fixed

Abnormal:
• Unable to maintain gaze
• May see a corrective saccade to regain focus

The ability to centrally suppress the VOR and allow head and eyes to move together VOR-C findings

Eyes move together back and forth between two targets

Completed with fixation

Normal: Eyes move conjugate (together) and move quickly and accurately
Normal with peripheral pathology, abnormal with central pathology

Snellen eye chart testing compared static VS dynamically
Dynamic: Head is oscillated 2-4 cycles within 20 degrees
Performed with fixation

Abnormal: More than a 2 line degradation is significant
Can be abnormal with central and peripheral pathologies

High frequency VOR where head is rotated appropriately 20 degrees
Can be specifically completed within the plane of a semicircular canal
• Superior vestibular nerve: tested if completed in the planes of the anterior or horizontal canal
• Inferior vestibular nerve: tested if completed in plane of the posterior canal
Performed with or without fixation

Abnormal: hypoactive VOR where eyes do not remain on target and travel with the skull. A corrective saccade will occur to get back to target. Can be abnormal in both central and peripheral disorders

Patient’s head is shaken by therapist and nystagmus is observed once head is static again
WITHOUT fixation only

Normal: No nystagmus after head is still
• Central disorders will have a normal result
Abnormal: More than 3 beats of post-head shaking nystagmus
• Peripheral disorders will have an abnormal result
• Indicative of unilateral hypofunction

Patient is instructed to hyperventilate by breathing 1 breath every second for 40 seconds
WITHOUT fixation only

Nystagmus can indicate central dysfunction or peripheral hypofunction
Symptoms within 20 seconds without nystagmus can indicate anxiety induced disorder

100 Hz of vibration is provided to mastoid process
WITHOUT fixation only

Positive test: Nystagmus, direction of nystagmus indicates hyperfunction of that ear (contralesional ear)
Abnormal positive test indicates peripheral pathology

Warm and cold water are irrigated in each ear separately and nystagmus is observed

Normal response:
• Cold water -> initial eye movement will look toward same ear, then followed by nystagmus occurring fast phase toward opposite ear
• Warm water -> initial eye movement will look away from ear being tested, followed by nystagmus occurring fast phase toward same ear

Impairment

Used to assess balance with and without vision and sensory input
Good for assessments but not comparing pre and post measures
4 Conditions:
• Eyes open firm surface
• Eyes closed firm surface
• Eyes open foam surface
• Eyes closed foam surface

Activity

8-item test including walking on even ground, walking with change in gait speed, walking with head turns, walking with 180 degree turn and stop, stepping over and around object, and stair negotiation (Similar to FGA)
Scores range from 0-24
Higher scores are better

Activity

Timed test to test patient’s ability to stand up from a chair, walk 3 M or 10 ft, pivot turn and return to chair
3-4 trials are conducted

Activity