Effects of transtympanic intermittent pressure therapy using a new tympanic membrane massage device for intractable Meniere's disease and delayed endolymphatic hydrops: a prospective study.

BACKGROUND: The retrospective study showed that the effect of the middle ear pressure treatment by the tramstympanic membrane massage (TMM) device was similar to that of the Meniett device. OBJECTIVES: The new TMM device named EFET device was prospectively evaluated in patients with Meniere's disease (MD) and delayed endolymphatic hydrops (DEH) and we compared the effects to the Meniett device. MATERIALS AND METHODS: 23 ears of 19 patients were treated with an EFET device, and 17 ears of 15 patients were treated with the Meniett device. All patients suffering from intractable MD and DEH were treated for 4 months. The insertion of a transtympanic ventilation tube was necessary for the Meniett device, but not the EFET device. RESULTS: In patients treated by the EFET and Meniett devices, the frequency of vertigo significantly improved after treatment. The distribution of vertigo outcomes at 4 months after treatment did not differ between patients treated with the both devices. CONCLUSIONS AND SIGNIFICANCE: Middle ear pressure treatment by the EFET device is effective and provides minimally invasive options for intractable MD and DEH like the Meniett device.

Systematic Review: Efficacy of Gufoni Maneuver for Treatment of Lateral Canal Benign Paroxysmal Positional Vertigo with Geotropic Nystagmus.

OBJECTIVE: In this rapid systematic review, we studied the efficacy of the Gufoni maneuver for the treatment of lateral canal benign paroxysmal positional vertigo (BPPV) with geotropic nystagmus. METHODS: A comprehensive search, including PubMed, Embase, Web of Science, and Cochrane as data sources, resulted in 44 original papers for randomized trials that compared the Gufoni maneuver with other maneuvers (date of search: April 23, 2013). Three studies (389 patients) remained after screening of title, abstract, and full text. RESULTS: After method assessment, 2 of these 3 studies were considered to have a low risk of bias and a high level of validity. The third study did not properly report the treatment allocation and blinding; moreover, outcome data were incomplete. The first 2 studies compared the Gufoni maneuver with a sham maneuver (and the barbecue roll in one study). The third study compared the Gufoni maneuver with a treatment with vestibular suppressants and with the barbecue roll (plus forced prolonged positioning). All 3 studies reported short-term results. Midterm results (1 month) were reported in 2 studies. CONCLUSION AND RECOMMENDATION: Given the variety in the comparative treatments and follow-up duration, all 3 studies showed that the Gufoni maneuver was more effective than the sham maneuver or treatment with vestibular suppressants. All agreed that the maneuver was easy to perform, which made it suitable for older, immobile, and obese patients. However, there were insufficient data to establish the relative efficacy of the Gufoni maneuver compared with other maneuvers.

An eye for an I: a 35-year-old woman with fluctuating oculomotor deficits and dissociative identity disorder.

Physiologic changes, including neurological or pseudo-neurological symptoms, occur across identity states in dissociative identity disorder DID) and can be objectively measured. The idea that dissociative phenomena might be associated with changes in brain function is consistent with research on the brain effects of hypnosis. The authors report a case of psycho-physiologic differences among 4 alter personalities manifested by a 35-year-old woman with DID. Differences in visual acuity, frequency of pendular nystagmus, and handedness were observed in this patient both when the alter personalities appeared spontaneously and when elicited under hypnosis. The authors consider several diagnostic possibilities for these findings and discuss whether prevailing treatment recommendations for DID patients could possibly be modified to ameliorate such visual and neurologic symptoms.

Effect of tongue stimulation on nystagmus eye movements in blind patients.

We have observed dramatic effects of tactile tongue stimulation on nystagmus eye movements in patients with acquired blindness, and we report these results. Six adult subjects (3 subjects with light perception or worse vision and 3 normal subjects) were included in this study. Causes of blindness included traumatic explosion, anterior ischemic optic neuropathy, and central retinal artery occlusion. Duration of blindness was 15, 3 and 1.5 years, respectively. A video eye tracking system (Eyelink 1000) was used to record eye movements. The eye movement recording (EMR) was repeated four times in a span of 20 min. Two of the EMRs were performed without tongue stimulation and two with tongue stimulation in randomized order. A tongue stimulus was applied to the surface of the tongue using a Brainport device that produces an electrical tactile stimulus. The nystagmus waveform characteristics and frequency were analyzed. We found that all blind subjects showed continuous jerk nystagmus with slow and quick phases, mainly in horizontal plane in their primary eye positions. The recorded nystagmus waveforms were jerk with linear velocity slow phases. When the tongue stimulus was applied, the frequency of nystagmus was significantly reduced by 47, 40, and 11%, and relative amplitude was reduced by 43, 45, and 6% for three blind subjects, respectively. In conclusion, we think our results that tongue stimulation influences nystagmus eye movements support a link between non-visual sensory input and ocular motor activity.

[Computer-aided techniques for the treatment and rehabilitation of patients suffering vertigo and balance disorders].

A new computerized method is proposed for the correction and elimination of undesirable illusory sensations (dizziness), vestibulo-oculomotor (nystagmus), and vestibulo-postural (imbalance) reactions. The method allows to teach the subject about how to avoid generalization of afferent signals over the effector mechanisms in the central nervous system by developing a fixational reflex employing delayed biological feedback for the assessment of efforts being exerted (self-control of training results). Three variants of application of this technique were evaluated depending on the type of stimulation software intended to induce illusory and oculomotor reactions of a defined sensory modality (visual, vestibular or combined). The study involved 30 subjects divided into three groups. They had been taught using the visual (group 1), vestibular (group 2) or combined (group 3) methods. Each group was comprised of an approximately equal number of subjects with vestibulopathies of either peripheral or central origin. The study demonstrated that the proposed approach allows to invoke, with the use of a computer stimulation software, abnormal illusory and vestibulo-oculomotor responses and inhibit them by developing the adequate fixational reflex. Comparative analysis of the results obtained by teaching the patients with the help of the three different methods revealed the dependence of their effectiveness on the level of disturbances in the vestibular system. The visual method of correction proved to be especially efficacious for the patients with peripheral vestibulopathy, and the vestibular methods for the patients with central vestibulopathy. Patients with combined peripheral and central vestibulopathy required the choice of training modalities (either visual or vestibular) on an individual basis.

Symptomatic Arnold-Chiari malformation and cranial nerve dysfunction: a case study of applied kinesiology cranial evaluation and treatment.

OBJECTIVE: To present an overview of possible effects of Arnold-Chiari malformation (ACM) and to offer chiropractic approaches and theories for treatment of a patient with severe visual dysfunction complicated by ACM. CLINICAL FEATURES: A young woman had complex optic nerve neuritis exacerbated by an ACM type I of the brain. INTERVENTION AND OUTCOME: Applied kinesiology chiropractic treatment was used for treatment of loss of vision and nystagmus. After treatment, the patient's ability to see, read, and perform smooth eye tracking showed improvement. CONCLUSION: Further studies into applied kinesiology and cranial treatments for visual dysfunctions associated with ACM may be helpful to evaluate whether this single case study can be representative of a group of patients who might benefit from this care.

The treatment of acute vertigo.

Vertigo and dizziness are very common symptoms in the general population. The aim of this paper is to describe the physical and pharmacological treatment of symptoms characterized by sudden onset of rotatory vertigo. Acute vertigo can be subdivided into two main groups: (1) spontaneous vertigo and (2) provoked vertigo, usually by postural changes, generally called paroxysmal positional vertigo (PPV). Sudden onset of acute vertigo is usually due to acute spontaneous unilateral vestibular failure. It can be also fluctuant as, e.g., in recurrent attacks of Ménière's disease. Pharmacotherapy of acute spontaneous vertigo includes Levo-sulpiride i.v., 50 mg in 250 physiologic solution, once or twice a day, methoclopramide i.m., 10 mg once or twice a day, or triethilperazine rectally, once or twice a day, to reduce neurovegetative symptoms; diazepam i.m., 10 mg once or twice a day, to decrease internuclear inhibition, sulfate magnesium i.v., two ampoules in 500 cc physiological solution, twice a day, or piracetam i.v., one ampoule in 500 cc physiological solution, twice a day, to decrease vestibular damage. At the onset of the acute symptoms, patients must lie on their healthy side with the head and trunk raised 20 degrees. The room must be quiet but not darkened. If the patient is able to swallow without vomiting, it is important to reduce nystagmus and stabilize the visual field with gabapentine, per os, 300 mg twice or three times a day. The first step of the physical therapy of acute vertigo is vestibular electrical stimulation, that is to say, a superficial paravertebral electrical stimulation of neck muscles, aimed to reduce antigravitary failure and to increase proprioceptive cervical sensory substitution. PPV is a common complaint and represents one of the most common entities in peripheral vestibular pathology. While the clinical picture is well known and widely described, the etiopathogenesis of PPV is still a matter of debate. Despite the different interpretation of PPV etiopathogenesis, the maneuvers described by Semont, Epley, or Lempert and their modifications are undoubtedly effective. For this reason the first therapeutic approach in acute provoked vertigo must be by means of one of these kinds of treatments.

[Semont maneuver vs. particle repositioning maneuver: comparative study]. / Manovra di Semont vs. Particle Repositioning Maneuver: studio comparativo.

In the present study 80 consecutive cases of PPV of the posterior semicircular canal are presented, with the purpose to evaluate the effectiveness of the treatment and to analyze the secondary Ny and re-test as indicators of the effectiveness of the therapeutic maneuver. The patients were treated in 40 cases with Particle Repositioning Maneuver (PRM) and in the other 40 with the Semont Maneuver, in an attempt to determine the secondary Nystagmus induced during treatment and any residual Paroxysmal Positional Nystagmus (PPNy) upon repetition of the Hallpike positioning after 15 minutes (re-test). Recovery was achieved in 80% of cases after the first session and in 95% of cases with the third session. PRM seemed to be slightly more effective. Secondary liberating Ny was frequently evoked (80%) and was reliable (75%) with the Semont Maneuver, while PRM yielded the liberating Ny in only 25% of cases, with lower reliability (70%). Reliability of the re-test with the Hallpike maneuver was high (80%) and the difference between the two techniques was negligible (78% in PRM and 85% in Semont). In conclusion, in terms of indicators of effectiveness, the Semont liberating Maneuver appears better in that it combines high therapeutic effectiveness (75% recovery in a single session) with a like percentage of liberating Ny (80%): this makes it possible to reserve the re-test and repetition of the therapeutic maneuver, performed during the same session, only in those cases that do not present liberating Ny (20% of cases). On the other hand, when the PRM is used, it appears better to rely on the high likelihood of effectiveness (85% in a single session) and then review the case directly at the next check-up rather than perform the Hallpike re-test in all cases that did not present the liberating secondary Ny (75%). In this way it is possible to select a small number of patients (22%) that still show PPNy (positive re-test) and for whom the therapeutic maneuver must be repeated.

Periodic downbeat nystagmus.

The authors observed a periodic downbeat nystagmus with a cycle of 3 minutes 30 seconds, beating downward for a period of 90 seconds every 2 minutes. It lasted 86 hours in a patient with severe hypomagnesemia associated with complications from scleroderma. There was no lesion on brain imaging, and an EEG performed during the nystagmus was normal, indicating that the most likely explanation for this periodic nystagmus is metabolic. This form of nystagmus may have resulted from severe hypomagnesemia, possibly associated with thiamine deficiency.

Randomised double-masked placebo-controlled trial of a treatment for congenital nystagmus.

Several therapies have been developed for congenital nystagmus (CN) but without placebo-controlled trials. We investigated a treatment which combined two therapies that had been advocated by several authors and were reported to improve visual acuity (VA). A placebo treatment was designed to mimic the time, attention, 'high tech' apparatus, and the explanation used in the experimental treatment. To each group, 38 subjects with CN were randomly allocated. Their VA and contrast sensitivity (CS) were assessed three times before undergoing treatment for 6 weeks and then once more. An improvement in VA occurred, however, this was not significantly different in the two groups. The improvement in CS was greater in the experimental than in the control group, but the difference failed to reach significance in most statistical tests. We conclude that putative therapies for CN should be assumed to be placebos until proven otherwise with randomized controlled trials.

Effects of acupuncture on foveation characteristics in congenital nystagmus.

AIMS/BACKGROUND: To examine the effects of acupuncture at the sternocleidomastoid muscles on foveation characteristics in congenital nystagmus. METHODS: Six patients with congenital nystagmus (CN) received a series of treatments consisting of two needles inserted into each sternocleidomastoid, stimulated by tapping gently every 5 minutes, for 20 minutes per session. Their eye movements were recorded using scleral search coils and changes in their CN waveforms analysed at each point in the treatment. Changes in the stability and duration of foveation periods were examined. RESULTS: Four of the six patients showed improved foveation at the commencement of treatment; three maintained this response throughout the treatment period and after the needles were removed. In two, the CN waveform itself was modified. CONCLUSION: This study and others involving afferent stimulation to the neck and face suggest that projections from these areas to the reticular formation and vestibular nucleus may alter the behaviour of the pathophysiological mechanism underlying congenital nystagmus.

Costenbader Lecture. Idiopathic infantile nystagmus: diagnosis and treatment.

Current concepts of idiopathic infantile nystagmus are summarized, with special attention to treatment and differential diagnosis of this condition. Advantages of the Anderson procedure over the Kestenbaum procedure are suggested for head turn associated with this condition, and the need for further studies is acknowledged. The importance of the extended slow phase in understanding the waveforms of infantile nystagmus is stressed. Our studies reinforce what I believe to be the natural history of infantile nystagmus, as well as the history of periodic alternating nystagmus. The critical delineation of diagnosing periodic alternating nystagmus is emphasized with respect to the type of operation to avoid overcorrection of head turns in patients with nystagmus. Continued searches for manifest latent nystagmus are important, because that condition is currently the only truly treatable nystagmus. I thank the American Association for Pediatric Ophthalmology and Strabismus for the privilege and honor of presenting the 1997 Costenbader Lecture.

Multifaceted treatment of congenital nystagmus: a report of 6 cases.

Patients with congenital nystagmus (CN) often have associated conditions (e.g., strabismus, high astigmatism, and binocular inefficiency) that also impair visual acuity. Unfortunately, individually used techniques directed at reducing nystagmus have generally produced only slight increases in Snellen acuity. We present case reports of six patients with nystagmus seen in our clinic (University of Houston, College of Optometry) to illustrate the use of problem-specific management to improve visual acuity and/or binocular function. The results suggest that a comprehensive management strategy should include treatment of all associated conditions as well as therapy to improve the characteristics of the nystagmus wave form.

[Spasmus nutans. A re-emergent pathology?]. / Spasmus nutans. Una patologia riemergente?

The authors report two cases of spasmus nutans (a clinical syndrome peculiar to infancy the complete form of which is characterised by nystagmus, rhythmic head movements and wryneck) in two extra-EEC infants. The following elements were present in both patients: scarce exposure to light, early introduction of whole cow's milk, rachitic stigmata, dark skin, poor socio-economic conditions and rapid and complete remission of symptoms following daily exposure to sunlight. It is important to distinguish spasmus nutans, a completely benign and self-restricting disease, from potentially severe conditions which may appear with similar symptoms. It should be expected that this clinical condition will become more frequent in view of the considerable increase in the size of the non-EEC population.

Changes in waveform of congenital nystagmus associated with biofeedback treatment.

A study was made of parameters of congenital nystagmus which responded to auditory biofeedback treatment. The parameters studied included foveation time, amplitude, and frequency. The patient's right retina was observed with an infrared television fundus camera, and the fundus image was recorded on video tape. The position of the eye during nystagmus, observed via the fundus camera and recorded on video, was analysed at every 1/60 second intervals. The displacement in degrees between the fixation target, projected on to the retina, and the foveola was measured for each interval. Using biofeedback, the subjects could voluntarily suppress nystagmus and prolong foveation time. A damping of the nystagmus amplitude, intensity, and frequency was observed. On the average the intensity decreased by about 40%, and the foveation time was prolonged by about 190%. After completion of the training all the patients reported a subjective improvement in their vision when suppressing their nystagmus. Possibly biofeedback training acts to reduce the nystagmus and extend foveation time, thereby improving the ability to fixate.

Visual improvement in an albinotic patient with an alteration of congenital nystagmus.

Biofeedback techniques were used to alter congenital nystagmus (CN) in an albino. In response to auditory cues, the patient was able to reduce the amplitude of the nystagmus by 50% or more. In response to a combination of auditory and visual cues, the patient was able to alter the waveform of the nystagmus in such a manner that progressively larger portions of each cycle of the nystagmus were spent with the eye relatively stationary. Presumably as a consequence of this alteration in waveform, the patient's visual acuity (VA) improved from 6/35 to 6/25. The results indicate that, although VA in albinos is limited ultimately by the presence of foveal hypoplasia, other components of the typical albinotic syndrome (such as the accompanying nystagmus) can add to the acuity reduction and should, therefore, be treated.

Ophthalmic applications of biofeedback.

Biofeedback therapy has been shown to be of value in the treatment of numerous psychological and physiological problems. In this paper, applications of biofeedback for correction of oculomotor abnormalities including strabismus, nystagmus and amblyopia, refractive error correction, reduction of intraocular pressure (IOP), and blepharospasm suppression are reviewed.