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Oscillopsia and Visuo-Vestibular Symptoms1 

Oscillopsia and Visuo-Vestibular Symptoms1
Oscillopsia and Visuo-Vestibular Symptoms1

Adolfo M. Bronstein

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date: 16 September 2021

Visual symptoms are common in patients reporting vertigo, dizziness or unsteadiness. In this chapter we will discuss them grouped as four clinical scenarios:

1) Double vision in vestibular disorders: clinicians should be wary when dizzy patients report double vision as this may herald the presence of brainstem pathology. In the patient with recent onset acute vertigo, this symptom should be actively elicited as it is a ‘red flag’ for possible posterior fossa stroke.

2) Complains of fuzzy or blurred vision should be pursued to see whether what the patient means is double (see above) or ‘wobbly’ vision (oscillopsia). A diagnostic algorithm for oscillopsia proposed by the author is included herein in which the leading question is “when does the oscillopsia occur?” Patients with bilateral vestibular failure report oscillopsia when they move, due to the loss of the vestibulo-ocular reflex. Patients reporting oscillopsia even when they are absolutely still are like to have a continuous nystagmus due to CNS lesion, such as downbeat nystagmus or pendular nystagmus. It is important to recognise paroxysmal oscillopsia (monocular, as in superior oblique myokimia, or binocular, as in vestibular paroxysmia) as this can often be treated successfully with Carbamazepine.

3) The syndrome of ‘visual vertigo’ carries a milder prognosis than the previous two topics, as it just refers to the visually-induced dizziness reported by many vestibular patients (for instance in supermarkets or while watching visual moving surroundings). Additional physiotherapy incorporating visuo-vestibular exercises and repetitive exposure to optokinetic stimulation are an effective treatment for ‘visual vertigo’ symptoms.

4) Unusual audio-visuo-vestibular symptoms often indicate that the patient suffers from the “Tullio phenomenon”, that is, visuo-vestibular symptoms induced by loud sounds. The more common cause is dehiscence of the superior semicircular canal.

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