Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft
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The spectrum of diagnoses of patients with dizziness as the leading symptom who consult a neurologist does not differ greatly from the spectrum of those who consult ear nose and throat (ENT) specialists or general practitioners (GP). The most frequent forms are benign paroxysmal positioning vertigo (BPPV), phobic postural vertigo, central vertigo disorders, Menière's disease, vestibular neuritis and bilateral vestibulopathy. ⋯ In the case of acute vertigo disorders in particular, a five-step procedure has proved to be helpful: the cover test to look for skew deviation as the central sign and component of the ocular tilt reaction, an examination with and without Frenzel's goggles to differentiate between peripheral vestibular spontaneous nystagmus and central fixation nystagmus, an examination of smooth pursuit and gaze-holding function and finally the head-impulse test to look for a deficit in the vestibulo-ocular reflex (VOR). Considerable advances have been made in the treatment of vertigo disorders in the last 10 years, e.g., cortisone for the treatment of acute vestibular neuritis, betahistine as a high-dosage, long-term treatment for Menière's disease, carbamazepine to treat vestibular paroxysmia and aminopyridine for downbeat nystagmus and episodic ataxia type 2.
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With specialist knowledge ophthalmologists can make a valuable contribution to the interdisciplinary work-up of patients with vertigo as the leading symptom. The neuro-ophthalmological examination of eye movements by an ophthalmologist and/or orthoptist is an important contribution because the various vertigo syndromes can only be correctly evaluated by a combined examination of the vestibular and ocular motor systems. ⋯ When taking the patient history the ophthalmologist should inquire about the type and duration of the vertigo, triggering or modifying factors and accompanying symptoms. This is followed by a systematic examination of the eye position and the different types of eye movements, the head-impulse test and a special examination to check for the presence of nystagmus.