Neuro-Ophthalmology, 32:93104, 2008

Copyright

c Informa Healthcare USA, Inc.
ISSN: 0165-8107
DOI: 10.1080/01658100701501109

CASE REPORT

Six Adult Cases with a Pseudo-Vestibular

Syndrome Related to Vergence
Abnormalities
Q. Yang, F. Jurion,
and M. P. Bucci ABSTRACT Saccades and vergence were studied in adults with vertigo but
Laboratoire de Physiologie de la without abnormal vestibular function; vertigo was associated with headaches
Perception et de lAction and occurred mostly after prolonged computer work. Horizontal eye move-
(LPPA), IRIS Group, UMR 7152,
ments from both eyes were recorded simultaneously with the IRIS SKALAR
CNRS-College de France, 11,
place M. Berthelot, 75005, device. Several of the specific characteristics of eye movements described previ-
Paris, France ously in controls were not present in vertigo adults: latency of convergence was
not longer than that of divergence; components of combined saccade-vergence
A. Lucek movements did not have longer latency than pure saccades or vergence;
Service dORL, Hopital
vergence velocity was not accelerated by the saccade during combined
Europeen Georges Pompidou,
75015 Paris, France movements. Relative to control adults, vertigo subjects showed longer latencies
of saccades to distant targets, divergence and convergence (tendency), slower
S. Wiener-Vacher speed for convergence, divergence and vergence components of combined
and D. Bremond-Gignac movements. Eye movement abnormalities could be useful for the differential
Service dORL, Hopital Robert
diagnosis of pseudo-vestibular syndrome (without vestibular dysfunction).
Debre, 48 Bld. Serurier, 75019,
Paris, France Oculomotor training is suggested for such subjects with vertigo to improve
their abnormal eye movements and reduce symptoms.
C. Orssaud
Service dOphtalmologie, KEYWORDS Vertigo; saccades; vergence; latency; speed
Hopital Europeen Georges
Pompidou, 75015 Paris, France

Z. Kapoula
Laboratoire de Physiologie de la
Perception et de lAction
(LPPA), IRIS Group, UMR 7152,
CNRS-College de France, 11,
place M. Berthelot, 75005,
Paris, France
Address correspondence to Dr. Qing
Yang, IRIS Group, LPPA, UMR 7152,
CNRSCollege de France, 11, place M.
Berthelot, 75005, Paris, France. Tel:
(331) 44.27.16.36; E-mail:
yangqing165@hotmail.fr
INTRODUCTION
Vertigo is a common symptom due to either peripheral or central vestibu-
lar dysfunction.7 However, some patients may lack typical signs of vestibular
dysfunction but still manifest vertigo symptoms. Anoh-Tanon et al.1 reported
that about 5% of children consulting the ENT service for vertigo and headaches
had normal vestibular function; they suggested that vertigo in such cases can be
a symptom of ocular disorders. De Haller et al.7 also diagnosed visual vertigo
based on the history and clinical examination in 11 from 242 vertigo or dizzi-
ness patients (4.5%). The symptoms immediately improved either on cessation
of the visual input or upon closure of the eyes. They suggested that the visual
vertigo could result from a mismatch between vestibular, proprioceptive and
visual inputs (neuro-ophthalmological examination was normal in all cases).

93
 In addition to vestibular eye movements, saccade
and vergence are important for exploration of 3D space
and for high quality 3D vision. Saccades are rapid
eye movements during which both eyes rotate in the
same direction; vergence is the slow eye movement in
opposite direction for the two eyes allowing to adjust
the angle of visual axes according to the depth of the
object of interest. Under natural conditions, most shifts
of the line of sight are to objects that lie in different
direction and different depths. Such gaze shifts require
a combination of a saccade and vergence movement.
The spatial and temporal characteristics of saccades and
vergence movements are different, indicating different
control mechanisms albeit interacting. For example,
the latency of saccades is longer to near targets than to
distant targets and the latency of convergence is longer
than that of divergence; combined saccade-vergence
movements have longer latencies than pure saccades or
vergence movements such as required when the targets
are aligned along the median plane.19,24,26 Another im-
portant characteristic for combined saccade-vergence
movements is that the saccade component is slower
(in speed) than the pure saccade while the vergence
component is faster than pure vergence.5,6,10,25,27 Stud-
ies of the variety of naturally made eye movements
in adults with vertigo symptoms are non-existent. In
children with vertigo but normal vestibular function,
saccade and vergence eye movements have been
studied by Bucci et al.;3,4 they reported abnormally
long latencies for saccades and vergence, particularly
for convergence, and for saccades combined with
convergence or divergence; reduced accuracy, long
duration and low speed for vergence relative to
normal children of matched age. Bucci et al.2 showed
poor binocular coordination of saccades in children
with vertigo.
Thus, there is evidence that pseudo-vestibular
syndrome, e.g. vertigo symptoms are associated with
abnormalities of saccades and mostly of vergence.
Bucci et al.3,4 proposed some mechanisms by which
such abnormalities could interfere actually with the
optimal adjustment of VOR gain according to the
viewing distance, thereby leading to incomplete visual
stabilization and thus to vertigo. Such hypothesis is in
line with electrophysiological and behavioral studies
showing the modulation of VOR by viewing distance.16
For children studied by Bucci et al.,3,4 cortical areas
such as the parietal cortex and the frontal lobe involved
Q. Yang et al.
in the control of eye movements have not been entirely
matured and this conceals oculomotor abnormalities.
However, for adults as cortical areas have been matured
and the oculomotor plasticity has been accomplished,
their deficit of eye movements may be different from
children despite the similarity of vertigo symptoms.
The main goal of this study is to explore whether
similar deficits exist in adults with a complaint of ver-
tigo but without vestibular abnormalities. First, latency,
accuracy and speed characteristics of different types of
eye movements are compared within subjects to con-
firm the differences known to exist in normal adults.
Secondly, for all the above mentioned parameters com-
parisons are made with values of the same types of
movements from control adult subjects of similar age
studied in the same conditions by our group.25,26
METHODS
Patients
Six subjects, aged 2856 years old (means 40.5 11.8
years), 2 males and 4 females, were recruited presenting
complaints of vertigo. All subjects were recruited in
the hospital and underwent vestibular, ophthalmology
and orthoptic examination. They were addressed to
us because no vestibular dysfunction was found and
the orthoptic examination revealed abnormalities
(see Table 1). Vestibular testing was extensive for some
of the subjects including caloric test, canal and otolith
examination, off vertical axis rotation with a computer
controlled rotating chair in the dark.2123 Conven-
tional hearing tests (tonal and speech audiometric
techniques) were also performed to examine the inner
ear function. The common symptoms reported by
all these patients were severe headaches and vertigo,
often after prolonged computer use (5 of them were
employed as secretaries). Subject S3 had orthoptic
training several years ago, subject S2 had such training
recently and subject S5 started taking medication lectil
16 (betahistine, against vertigo) a week before our
oculomotor testing. No other subject took medication.
All these subjects were regularly follow-up by the
ophthalmology service due to their persisting vergence
abnormalities. The investigation adhered to the tenets
of the Declaration of Helsinki and was approved by
the institutional human experimentation committee.
Informed consent was obtained from each subject after
the nature of the procedure had been explained.
94
TABLE 1A Clinical characteristics of subjects
Subject Visual Stereoacuity NPC Heterophoria Divergence Convergence Main clinical
(years) acuity (TNO) (cm) (pD) (pD) pD materials

S1 LE:10/10 40 6 Far: 4E Far: 2 Far: 25 Vertigo, headache

(28) RE:10/10 Near: 4E Near: 6 Near: 40 Visual fatigue
S2 LE:10/10 40 6 Far: 6x Far: 2 Far: 16 Vertigo, headache
(31) RE:10/10 Near: 1x Near: 12 Near: 18 Visual fatigue

S3 LE:10/10 40 6 Far: ortho Far: 4 Far: 40 Vertigo

(37) RE:10/10 Near: ortho near: 14 Near: 40 Visual fatigue

S4 LE:10/10 40 4 Far: ortho Far: 4 Far: 40 Rotatory vertigo

(56) RE:10/10 Near: 6x Near: 12 Near: 40 Visual fatigue
S5 LE:10/10 120 6 Far: 8 Far: 12 Vertigo
(37) RE:10/10 Near: 12 Near: 40 Medication of antivertigo
S6 LE:10/10 120 20 Far: 3x Far: 4 Far: 6 Vertigo
(54) RE:10/10 Near: ortho Near: 6 Near: 25

Note: NPC - near point of convergence.

Visual Display
The visual display consisted of LEDs (each LED on
2.9 mm of diameter) placed at two isovergence circles:
one at 20 cm from the subject, and the other at 150 cm.
At each viewing distance three LEDs were used; one
at the center and the other at 20 . At 20 cm, the
required mean vergence angle for fixating any of these
three LEDs was 17 ; at 150 cm such angle was 2.3 .
Oculomotor Tasks
In a dark room the subject was seated in an adapted-
chair with a head and chin support. He/she viewed
binocularly and faced the 3D visual display of the
LEDs. The distance between the subject and the close
isovergence surface was at 20 cm. The visual display of
the LEDs was placed at eye level to avoid vertical eye
movements.
Each trial started by lighting a fixation LED at the
center of one of the circles (distant or close). After
a 1.5 s fixational period the central LED was turned
off and a target-LED appeared for 1 s. When the
target-LED was on the center of the other circle it
called for a pure vergence eye movement, along the
median plane. When it was at the same circle it called
for a pure saccade (left or right), and when it was lateral
and on the other circle the required eye movement was
a combined saccade and vergence eye movement. Note
that our use of saccades both to near and to distant
targets allowed us to keep target direction and depth
unpredictable for all trials. All target LEDs for saccades
were at 20 . All targets along the median plane required
a change in ocular vergence of 15 ; similarly, combined
movements required a saccade of 20 and a vergence of
15 . In each block, the three types of eye movements
were interleaved randomly. Each block contained 72
trials, i.e. 12 trials per type of movement, saccades to
distant targets, saccades to near targets, convergence,
divergence, combined convergent movements and
combined divergent movements. For each subject, two
blocks were run, separated by a rest of few minutes; cal-
ibrations were repeated at the beginning of each block.
For calibration the subject made a sequence of sac-
cades to a LED target jumping from zero to 10 ,
20 . During each of these trials, the target remained
at each location for 2 s; the subject was instructed to

TABLE 1B Normal values of near point of convergence (NPC), of heterophoria and of the range of divergence and convergence
amplitudes at far and close viewing distance measured in adults

Heterophoria
Stereoacuity NPC (cm) (Dp) Divergence (Dp) Convergence (Dp)

<60 <10 Far: 02 XP Far: 59 Far: 1523

Close : 46 XP Close : 1523 Close: 1824

95 Vergence Abnormalities in a Pseudo-Vestibular Syndrome

fixate the LED as accurately as possible; the LED pre-
sentation was sufficiently long to allow accurate and
stable fixation. From these recordings were extracted
the calibration factors.
Eye Movement Recording
Horizontal movements from both eyes were
recorded simultaneously with the IRIS SKALAR
device. Eye position signals were low-pass filtered with
a cut-off-frequency of 200 Hz and were digitized with
a 12-bit analogue-to-digital converter and each channel
was sampled at 500 Hz. This system has an optimal res-
olution of 2 minutes of arc and linear range of 25
degrees. Data collection was directed by REX, software
developed for real-time experiments and run on a PC.
Data Analysis
Calibration factors for each eye were extracted from
the saccades recorded in the calibration task; a linear
function was used to fit the calibration data. From the
two individual calibrated eye position signals we derived
the vergence signal (left eye right eye) and the con-
jugate signal ((left eye + right eye)/2). Figure 1 shows
an example of pure saccades (A), Pure convergence (B),
combined convergent movements (C), combined diver-
gent movements (D). For each type of these movements
are shown the saccadic or conjugate components and
the vergence or disconjugate components. The onset
of a pure saccade or of the saccadic component of the
combined movements was defined as the time when eye
velocity exceeded 450 /s (mark i in figure A, C or D);
the offset when eye velocity dropped below 10 /s (mark
e in figure A, C, D). The onset and the offset of the
vergence signals (for pure vergence movement and for
the vergence component of the combined movements)
were defined as the time point when the eye velocity ex-
ceeded or dropped below 5 /s (marks i and e in figures
B, C, D, respectively). The placement of the markers by
the computer was verified by one of the investigators
scrutinizing saccade and vergence components on the
screen. Eye movements in the wrong direction, move-
ments with latency shorter than 100 ms or longer than
1000 ms or movements contaminated by blinks were
rejected. These criteria are standard, also used by others
[9, 17, 26]. About five percent of trials had to be rejected.
For all types of eye movements, we measured the
latency, the time difference between onset of eye
movement (i) and onset of target; the gain, the ratio
Q. Yang et al.
of amplitude of eye movements (amplitude difference
between i and e in degree) to target amplitude; the
mean velocity, ratio of amplitude of eye movement to
duration of eye movement (time difference between
i and e). To evaluate the difference between any two
different types of eye movements the non-parametric
Wilcoxon test was used. The U-Mann-Whitney test
was used to compare the difference between adults
with vertigo and control adults.
RESULTS
Latency
Differences According to Type
of Movement
Figure 2 presents individual and group mean laten-
cies together with standard errors for each type of eye
movements, pure saccade or saccade components of
combined movements (A), and pure vergence or ver-
gence components of combined movements (B) in
adults with vertigo. The non-parametric Wilcoxon test
showed that, as in normals, the latency for saccades to
distant targets or saccade components of combined di-
vergent movements was significantly longer than that
for saccades to near targets (both Z = 2.2, p < 0.05).
In contrast, there was no statistically significant differ-
ence of latencies between convergence and divergence
(Z = 0.73, p = 0.46), nor between pure vergence and
vergence components of combined movements (both
Z < 1.15, p > 0.05), nor between saccades to distant tar-
gets and saccade components of combined convergent
movements (Z = 0.10, p = 0.92).
Comparison with Normal Adults
The nonparametric U-Mann-Whitney test was used
to compare mean latencies between adults with vertigo
and control adults (15 subjects) without vertigo symp-
toms (horizontal lines in figure indicating mean values
of control subjects) data extracted from the study of
Yang et al. [24]. Latencies of saccades to distant targets
were significantly longer for subjects with vertigo than
for control adults (U = 18, p < 0.05), but there was no
significant difference for saccades to near targets (U =
38, p = 0.59). Latency of divergence was significantly
longer for subjects with vertigo than for control adults
(U = 18.5, p < 0.05). For convergence, the difference of
latency between these two adult groups was marginally
significant (U = 21, p < 0.06). There was no significant
96
FIGURE 1 Examples of eye movements. (A) saccades (to left or to right); (B) vergence ( convergence or divergence); (C) combined
convergent movements (with saccades to left or to right); (D) combined divergent movements (with saccades to left or to right). On the
right side of each figure shown the excursion of the target. The arrows i and e indicate the onset and the end of eye movements,
respectively. Time at 0 ms indicates the target onset.

97 Vergence Abnormalities in a Pseudo-Vestibular Syndrome

FIGURE 2 Individual mean latency with standard errors (SE) of saccades or saccade component of combined movements (A), and
of vergence or vergence components of combined movements (B). The right bar for group means based on 6 subjects, on which the
horizontal line is mean value form normal adults. * indicates the statistically significant difference in latency between normal adults and
subjects with vertigo.

Q. Yang et al. 98
difference of latency for any components of combined
eye movements between the two adult groups (all U >
25, p > 0.05). At the individual level, inspection of
the data in Figure 2, shows that the above conclusion
applies for the majority of subjects except subject S5
who was taken a drug against vertigo.
In summary, vertigo subjects have longer latencies
of the majority of eye movements than for controls.
Because of such slowing the normal differences between
types of movements appear less for the group of vertigo
subjects.
Accuracy
Differences According to Type
of Movement
Figure 3 presents individual and group mean gains
(eye-movement amplitude/target amplitude) together
with standard errors for pure movements (saccade or
vergence, A) and combined movements (B) in adults
with vertigo. As there was no significant difference in
the accuracy between saccades to distant targets and to
near targets, nor between the two saccade components
of combined movements (convergent and divergent)
they were grouped. The Wilcoxon test showed that
the mean gain (saccade amplitude/target amplitude) of
saccade components of combined movements was sig-
nificantly reduced relative to pure saccades (Z = 2.2, p <
0.05), but there was no difference between convergence
and divergence (Z = 0.73, p = 0.46), nor between pure
vergence and corresponding vergence components of
combined eye movements (both Z < 0.73, p > 0.05).
Comparison with Normal Adults
The nonparametric U-Mann-Whitney test showed
no significant difference of gains of any type of eye
movements between adults with vertigo and control
adults (All U > 27, p > 0.05).
Mean Velocity
Differences According to Type
of Movement
Figure 4 presents individual and group mean veloc-
ities together with standard errors for pure movements
(saccades or vergence, A) and combined movements
(B) in adults with vertigo. There was no significant dif-
ference of mean velocities between saccades to distant
targets and to near targets, nor between two saccade
components of combined movements (convergent and
99
divergent) and they are regrouped. The Wilcoxon test
showed significantly higher mean velocity for conver-
gence than for divergence (Z = 1.99, p < 0.05). To test
the saccade-vergence interaction, i.e. the well-known
acceleration of vergence by saccades in combined
movements [24], we will compare pure vergence with
vergence components of combined movements, pure
saccades with saccade components of combined move-
ments. Contrary to what is known in controls [24],
there was no significant difference of mean velocities
between vergence and vergence components of com-
bined movements (Z = 0.31, p = 0.75 for convergence
and Z = 0.94, p = 0.35 for divergence). Similar to
controls, adults with vertigo still showed significantly
higher mean velocities for pure saccades than saccade
components of combined movements (Z = 2.2, p <
0.05). Thus, in subjects with vertigo the saccade did
not accelerate vergence but it was itself slowed.
Comparison with Normal Adults
The nonparametric U-Mann-Whitney test was used
to compare mean velocities between adults with vertigo
and control adults (mean values indicated by horizontal
lines in Fig. 4). Relative to controls, adults with vertigo
showed significantly lower mean velocities for conver-
gence (U = 0, p < 0.001), for divergence (U = 14,
p < 0.05), and for convergence components (U =11,
p < 0.01) or divergence components (U = 0, p < 0.001)
of combined movements. There was no statistically sig-
nificant difference of mean velocity for pure saccades
(U = 27, p = 0.16), for saccade components of com-
bined movements (U = 32, p = 0.31).
DISCUSSION
To summarize, the data show that adults with vertigo
without abnormal vestibular function or other pathol-
ogy present abnormalities in their eye movements,
mainly in their temporal-dynamics parameters (laten-
cies, speed). Two types of abnormalities are seen. Firstly,
one does not observe several of the specific characteris-
tics of eye movements described previously in controls.
Vertigo adults show no longer latency for convergence
than for divergence nor longer latency for correspond-
ing components of combined movements than for
pure movements (saccades or vergence); they show no
higher speed for vergence combined with saccades than
for vergence alone. Secondly, relative to values from
control adults, they show longer latencies of saccades
Vergence Abnormalities in a Pseudo-Vestibular Syndrome
FIGURE 3 Individual mean gain with standard errors (SE) of pure movements (saccades, convergence or divergence, A), and combined
movements (B). The right bar for group means based on 6 subjects, on which the horizontal line is mean value form normal adults. Dotted
horizontal lines indicate a gain of 1, which corresponds to a perfectly accurate eye movement (eye movement amplitude = target excursion
amplitude).

to distant targets, for divergence and convergence
(tendency), slower speed for convergence, divergence
and vergence components of combined movements.
These findings will be discussed further next.
Latency
Saccades to Distant-Near Targets
Latency of saccades is longer to distant targets than
to near targets in normal adults.24,26 For adults with
vertigo a similar difference exists, and is even more ac-
centuated than in control adults (63 vs 17 ms). Yang
et al.24 considered that this difference between viewing
distances could be due to facilitation of oculomotor
or attention disengagement at close. The same factors
could explain the prolongation of latency for saccades
to distant targets in adults with vertigo. Relative to con-
trol adults, adults with vertigo showed longer latency
for saccades to distant targets but not for saccades to
near targets. It seems that initiating saccades to distant

Q. Yang et al. 100

FIGURE 4 Individual mean speed (mean velocity) with standard errors (SE) of pure movements (saccades, convergence or divergence,
A), and combined movements (B). The right bar for group means based on 6 subjects, on which the horizontal line is mean value form
normal adults. indicates the statistically significant difference in speed between normal adults and subjects with vertigo.

targets is more difficult in adults with vertigo and the fa-
cilitation of disengagement of oculomotor fixation and
visual attention to near targets allow them to maintain
normal behavior.
Convergence-Divergence
Control adults studied in same conditions showed
longer latency of convergence than of divergence.24
Adults with vertigo showed no difference of latency
between convergence and divergence. A possible rea-
son was that the increase of latencies for both con-
vergence and divergence relative to control adults hide
the difference; convergence tended to have longer la-
tency than divergence but did not reach statistical sig-
nificance (252 vs 240 ms, Z = 0.73, p = 0.46). The
examination of individual data in this study showed
that two vertigo subjects showed longer latency for di-
vergence. The more solid result of clinical relevance
is the increase of latencies for both convergence and
divergence for adults with vertigo compared to con-
trols. These results are compatible with the study in
children with vertigo,4 which also showed increased

101 Vergence Abnormalities in a Pseudo-Vestibular Syndrome

latency of convergence and divergence by 145 ms and localize the target in depth correctly. However, adults
50 ms longer than of control children; in adults with with vertigo maintained a good accuracy for vergence
vertigo latencies are longer by 33 ms and 42 ms relative although they have vergence problems in the clinical
to control adults. tests. The dual-mode model of vergence control in-
cludes a fast, open-loop movement and a slower move-
Pure Versus Combined ment under visual feedback control; such control would
allow us to obtain accurate vergence movements.11 The
In controls (adults or children), latencies of both
dual-mode model could explain why despite the latency
saccade and vergence components of combined
prolongation of vergence the accuracy was maintained
movements are longer than corresponding pure eye
normal as they could adjust their accuracy on the
movements [19, 24]; this is believed to be due to the
basis of visual feedback (the slow-control mechanism).
higher complexity of preparation of two components.
But for pure saccades and saccade components, our
Combined movements were not longer to prepare for
vertigo subjects showed as good accuracy as controls,
vertigo adults except saccade components of combine
similar to vertigo children studied by Bucci et al.3 Note
divergent movements relative to pure saccades to
that these saccades are rapid movements and visual
near targets. However, the absence of such difference
feedback during their execution cannot modify their
is due to the fact that pure movements are already
accuracy. Therefore, one should conclude that all eye
longer to initiate than in controls. Saccades to distant
movements, fast or slow, remain accurate in vertigo
targets, convergence and divergence were initiated with
adults.
longer latencies in adults with vertigo than in controls.
Takagi et al. [19] proposed the conceptual model for
controlling combined movements. Once a common Speed
decision to generate an eye movement to a new target
The abnormality of speed of eye movements con-
in direction and in depth is made for saccades and
cerns the interaction between saccades and vergence
vergence at the same time, the activities are passed to
during their combination. In controls, saccades com-
parallel saccade and vergence trigger mechanisms. This
bined with vergence are slowed down relative to pure
model could explain the different initiation of saccade
saccades while vergence combined with saccade are
and vergence during combined movements. Moreover,
speeded relative to pure vergence.6,27 Zee et al.27 pro-
it also suggested that the latency prolongation during
posed three different models to attempt to explain the
combined movements was not simple addition based
interaction between saccade and vergence, i.e. a model
on pure movements but there existed an interaction
based on the existence of saccade-related vergence
between saccade and vergence. For adults with vertigo,
burst neurons (SVBN), a model based on separated
the latency of pure eye movements (saccades or
right and left eye burst neurons and a model based on
vergence) was increased to the level of combined
premotor vergence velocity neurons. Their simulation
movements while combined saccade-vergence move-
results favored the first and third model. The SVBN
ments maintained their initiation time like in control
model was modified recently by Kumar et al.,15 which
adults.
is a Hering-type model that assumes separate saccadic
In general, latency initiation problems are believed
and vergence systems but common commands to the
to be cortical dysfunction of parietal and frontal
two eyes. A different view is presented in a Helmholtz-
areas.12,1718,2527 The abnormalities observed here
type model, which hypothesizes that monocular burst
indicate problems of this level particularly for iso-
neurons could determine the dynamic properties of
lated convergence, divergence and saccades to distant
both conjugate (saccadic) and disconjugate (vergence)
targets.
components.14 Electrophysiological evidence exists to
support both Hering- and Helmholtz-type models, but
Accuracy the interpretation of these data remains controversial.15
Bucci et al.3 reported that children with vertigo Despite theoretical controversies behavioral data show
showed low accuracy for both convergence and diver- convincingly that vergence is accelerated by the
gence. They suggested that such poor vergence accuracy saccade. Yet, in our subjects vergence speed was not
could be caused by a reduced ability of their subjects to increased by the saccade. Most likely, the central

Q. Yang et al. 102

interaction between saccadic and vergence systems is
dysfunctioning in such subjects at the brainstem level.
Possible Dysfunction of Neural
Structures Involved in Vertigo
Many cortical and subcortical structures are in-
volved in the control of saccades and vergence. For
example, posterior parietal cortex (PPC), frontal eye
field (FEF) and prefrontal cortex (PFC) are involved
more in the control of initiation of both saccades
and vergence.12,13,16,18 At the brainstem level distinct
circuits are known to control saccades and vregence:
the paramedian pontine reticular formation (PPRF)
for saccades, the mesencephalic reticular formation
(MRF) for vergence.16 Our results show in adults with
vertigo the existence of a specific problem initiating
saccades to distant targets only but a general problem
for vergence, e.g. latency prolongation and low speed
for both convergence and divergence, and no accel-
eration of vergence by the saccade during combined
movements. Vergence problems could be related to
cortical-subcortical mechanisms that are specific to
vergence and its interaction with saccades.
Clinical Consideration
Vertigo without abnormal vestibular function is
often difficult to diagnose in clinic. Our results showing
that adults with vertigo but without abnormal vestibu-
lar function had both saccades and vergence problems,
particularly for vergence, could provide supplementary
tools for helping to diagnose such functional problems.
Orthoptic vergence training is widely used by clinicians
to treat vergence abnormalities.20 Our group3,4 demon-
strated that the orthoptic vergence training in children
with vertigo but without abnormal vestibular function
could eliminate vertigo symptoms, improve vergence
capabilities clinically assessed, shorten latency of eye
movements and improve the accuracy of different eye
movements. Perhaps the orthoptic vergence training
is also effective for adult subjects to improve their eye
movements, but this needs further investigation. We
suggest that the oculomotor training, i.e. making a
number of saccades, vergence and their combination
everyday or periodically could be used as the im-
provement training for subjects with vertigo. Fischer8
reported that even for normal subjects, saccade latency
after the training of a repetition of 200 saccades per
day for a period of 10 days could be decreased.
103
Conclusion
The present study reports abnormalities in saccades
and vergence for adults with vertigo but without ab-
normal vestibular functions. Relative to control adults,
these subjects had latency prolongation and speed slow
for some types of eye movements, particularly for ver-
gence, pure or combined. These results could be use-
ful for the differential diagnosis of pseudo-vestibular
syndrome (without vestibular dysfunction). Oculomo-
tor training is suggested for such subjects with vertigo
to improve their abnormal eye movements and reduce
symptoms.
ACKNOWLEDGMENT
Q. Yang was supported by European Union (QLK6-
CT-2002-00151: EUROKINESIS) and CNRS/CTI,
Handicap contract.
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