Subjective Visual Vertical in Idiopathic Bilateral Vestibular Hypofunction: Enhanced Role of Vision, Neck, and Body Proprioception

Introduction: We aimed to study the participation of proprioceptive and visual inputs in subjective visual vertical (SVV) in bilateral vestibular hypofunction and in normal subjects. Study Design: Prospective case-control study. Setting: Tertiary referral center. Materials and Methods: SVV (six replicates) was measured on a tiltable rehabilitation seat in 26 adult patients with idiopathic bilateral vestibular hypofunction (IBVH) and 33 adult controls. Subjects were asked to place vertically a 45 degrees-tilted red line on a screen (three replicates to left and three to right alternatively) using a remote control in total darkness and in seven body positions: vertical, head, and body left-and right-tilts to 12 and 24 degrees, and then body left-and right-tilt to 24 degrees with the head upright. Results: In the vertical position, SVV did not differ between IBVH and controls. Patients with IBVH were more sensitive to body tilt than controls (SVV: -8.1 +/- 4.66 degrees for IBVH versus -0.2 +/- 3.23 for control at 24 degrees body and head left-tilt, p < 0.0001, unpaired t test). The visual attraction effect defined by a deviation of the SVV to the side of the initial line presentation appeared to be higher in the IBVH than in controls suggesting higher visual dependence in IBVH. Placing the head upright while the body was still tilted significantly reduced this difference. Similar results were observed for the right-tilts. Conclusion: Not only otolithic function but also visual plus body and neck proprioceptive entries participate in SVV. The influence of vision and proprioception appears to be enhanced in case of IBVH.