Evaluation of vestibular and visual oculomotor function

The visual system interacts synergistically with the vestibular system. A normally functioning vestibulo-ocular reflex is necessary but not sufficient for optimum visual acuity during head motion. Studies of dynamic visual acuity, the acuity achieved during relative motion of visual targets or of the observer, indicate that motion of images on the retina markedly compromises vision. The vestibulo-ocular reflex normally provides a substantial measure of stabilization of the retina during head movements, but purely vestibular compensatory eye movements are not sufficiently precise for optimal vision under all circumstances. Other mechanisms, including visual tracking, motor preprogramming, prediction, and mental set, interact synergistically to optimize the gain (eye velocity divided by head velocity) of compensatory head movements. All of these mechanisms are limited in their capacity to produce effective visual-vestibular interaction at higher rotational frequencies and velocities. It is under these conditions that vestibular deficits give rise to symptoms of oscillopsia. Patients having vestibular lesions exploit mechanisms of visual-vestibular interaction to compensate by substitution for deficient vestibular function. Thus, for accurate topographic clinical diagnosis of vestibular lesions, testing conditions should isolate purely vestibular responses. This may be done by testing reflex eye movements during passively generated rotations in darkness, or perhaps by testing during other types of motion under conditions of extreme frequency and velocity sufficient to attenuate the effects of visual-vestibular interaction. This article reviews clinical tests of vestibular function in relation to synergistic interactions with vision.