Abstract Details

Title Ocular counter-roll during a Ménière's attack: evidence of ictal utricle pathway imbalance using fundus photography

Topic Neuro-ophthalmology/Neuro-otology

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-004

Objective

To call attention to unrecognized ictal vestibular manifestations of Ménière's disease.

Background

During Ménière's disease (MD) attacks, static semicircular canal (SCC) asymmetry causes spontaneous nystagmus (ipsilesional when excitatory, and contralesional when inhibitory). Acute dynamic SCC dysfunction can cause an abnormal head impulse test (HIT, e.g., acute vestibular neuritis), although the HIT can be normal during a MD attack. Documentation of ictal otolith (utricle and saccule) dysfunction using vestibular evoked myogenic potentials (VEMPs) has rarely been reported. We describe the first case, to our knowledge, of a patient presenting with a Ménière's attack in whom an ocular counter-roll (OCR, from static utricle pathway imbalance) was documented using fundus photography.

Design/Methods One case report of a patient with an OCR observed during a MD attack.

Results A 65-year-old man with known history of bilateral MD presented during a typical vertigo attack, and testing demonstrated: 1) Video-oculography (VOG) – spontaneous horizontal-torsional, unidirectional right beating nystagmus, following Alexander’s law; 2) Video HIT (vHIT) – low gain (0.49 where <0.7 is considered abnormal) in the plane of the left horizontal SCC; 3) fundus photography – OCR with the top poles of both eyes rotated toward the left ear, in the absence of other features of the ocular tilt reaction (OTR, including OCR, head tilt, skew deviation). The HINTS exam (head impulse, nystagmus, test of skew) suggested a left peripheral vestibulopathy, and a Ménière's attack was diagnosed given his history. Three weeks later testing was repeated while asymptomatic: 1) VOG – no nystagmus; 2) vHIT – normal horizontal SCC gain (0.73); 3) fundus photography – no OCR. For more, visit the NOVEL collection:

Conclusions Using a non-mydriatic fundus camera, we were able to document an ictal OCR in MD. Its presence suggested utricle pathway imbalance, offering insight into the labyrinthine structures that may be involved during a MD attack.

Authors/Disclosures
Elizabeth A. Fracica, MD, MPH (Massachusetts General Hospital) PRESENTER	Dr. Fracica has nothing to disclose.
Daniel R. Gold, DO (Johns Hopkins)	Dr. Gold has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer . Dr. Gold has received publishing royalties from a publication relating to health care.

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