Patient is having more imbalance than dizziness while standing up and getting down,during namaz also since 2-3 weeks no other signs
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Based on my thorough review of this VNG report, I can provide a comprehensive interpretation. The library did not have a dedicated VNG/oculomotor analysis textbook, but the findings are interpretable from the data provided.
VNG Report Interpretation — Mohammad Ali, 73M
Complaint: Imbalance > dizziness on standing/sitting (during namaz), 2–3 weeks
FINDINGS SUMMARY
1. Saccades — Within Normal Limits
| Parameter | Values | Interpretation |
|---|---|---|
| Horizontal velocity | 426–529 °/s | Normal range (>200 °/s) |
| Precision | 85–93% | Adequate |
| Latency | 360–442 ms | Slightly prolonged but acceptable in a 73-year-old |
Vertical saccades also showed normal velocity (346–470 °/s) with acceptable precision. No dysmetria, no hypometria suggesting cerebellar or basal ganglia pathology.
2. Smooth Pursuit — SIGNIFICANTLY REDUCED (Abnormal)
| Direction | Right Eye | Left Eye |
|---|---|---|
| Horizontal 0.2 Hz — Rightward | 0.43 | 0.45 |
| Horizontal 0.2 Hz — Leftward | 0.47 | 0.56 |
| Horizontal 0.4 Hz — Rightward | 0.30 | 0.52 |
| Horizontal 0.4 Hz — Leftward | 0.17 | 0.65 |
| Vertical 0.2 Hz — Downward | 0.47 | 0.48 |
| Vertical 0.4 Hz — All | 0.30 | 0.30–0.31 |
Normal pursuit gain ≥ 0.7–0.8 for 0.2 Hz; ≥ 0.5–0.6 for 0.4 Hz
Interpretation:
- Horizontal pursuit is bilaterally reduced, especially the right eye at 0.4 Hz (gain 0.17–0.30 — severely reduced)
- Vertical pursuit is bilaterally reduced at both frequencies
- Asymmetric horizontal pursuit (right eye much worse at 0.4 Hz) — raises concern for a central pathway lesion (cerebellar vermis / flocculus / brainstem) or age-related pursuit degradation
- In a 73-year-old, some reduction is expected; however, this degree of impairment, especially the marked asymmetry and vertical involvement, is clinically significant
3. Optokinetic Nystagmus (OKN)
| Direction | Gain |
|---|---|
| Left→Right 10° | 0.92/0.84 ✓ |
| Right→Left 10° | 0.73/0.74 ✓ |
| Top→Bottom 10° | 1.13/0.85 ✓ |
| Bottom→Top 10° | 0.81/0.70 ✓ |
| Left→Right 20° | –/0.72 (right eye absent) |
| Right→Left 20° | 0.65/0.61 |
| Vertical 20° | Both — no gain recorded |
OKN at 10° is relatively preserved. Reduced/absent at 20° stimulation. This is consistent with reduced smooth pursuit pathways. No directional OKN asymmetry suggesting unilateral peripheral lesion.
4. Spontaneous Nystagmus
- In light: No spontaneous nystagmus (normal)
- In dark: No spontaneous nystagmus (normal)
- Head shake nystagmus: Negative (normal)
No peripheral vestibular lesion (e.g., unilateral vestibular hypofunction) evidenced here.
5. Gaze Tests
- With fixation (center, left, right, up, down): All normal — no gaze-evoked nystagmus
- Without fixation: Low-amplitude, low-frequency nystagmus noted in multiple positions:
- Center without fixation: SPV 3.36 °/s right eye (borderline)
- Left without fixation: SPV 7.92/6.40 °/s — mild gaze-evoked nystagmus left
- Right without fixation: SPV –7.52 °/s left eye — mild gaze-evoked nystagmus right
- Up without fixation: 6.73 °/s left eye vertical
Bidirectional gaze-evoked nystagmus without fixation is suggestive of central (cerebellar/brainstem) involvement rather than peripheral pathology.
6. Dix-Hallpike Test
| Position | Nystagmus | Interpretation |
|---|---|---|
| DHP Right — Supine Head Ext. + Right | Vertical nystagmus: SPV –6.61 °/s, fast phase 77.74°, freq 1.96 Hz (right eye only) | Positive — right side |
| DHP Right — Returning to Sit | Nystagmus in both eyes (vertical + horizontal components) | Reversal nystagmus present ✓ |
| DHP Left — Supine Ext. + Left | Low-amplitude nystagmus (0.57–0.73 Hz) | Weakly positive |
| DHP Left — Returning to Sit | Negative (second trial) |
Dix-Hallpike is positive on the RIGHT side with predominantly vertical/torsional nystagmus. This is consistent with right posterior canal BPPV, though the nystagmus parameters (persistently recurring, seen in both eyes on return) warrant clinical correlation.
7. McClure-Pagnini (Supine Roll) Test — Positive Bilateral
| Position | Horizontal SPV | Frequency |
|---|---|---|
| Sit to Supine | Vertical –7.08 °/s right eye | Present |
| Right Lateral | Horizontal –6.10 °/s right eye (geotropic) | 0.64 Hz |
| Left Lateral | Horizontal 9.61/6.21 °/s (geotropic) | 1.07/0.95 Hz |
| Left Supine Neutral | Vertical –10.65 °/s right eye | 0.89 Hz |
Persistent horizontal nystagmus in both lateral positions (geotropic pattern) — this is the pattern seen in horizontal (lateral) canal BPPV (canalith repositioning form). The nystagmus is more prominent in the left lateral position, suggesting the right horizontal canal may be involved (debris lying towards right side is stimulated when left ear is down).
8. Subjective Visual Vertical (SVV)
| Condition | Deviation |
|---|---|
| Clockwise | –1° Left |
| Anticlockwise | –7° Left (abnormal) |
| Blank background | –1° Left |
Normal SVV: within ±2–3°
The anticlockwise trial shows a –7° left deviation — this is a significant tilt, suggesting utricular or otolithic dysfunction on the right side (ipsilesional tilt toward right peripheral or contralateral central pathology). The inconsistency across trials (–1° vs –7°) may reflect patient cooperation variability, but this finding deserves attention.
CLINICAL INTERPRETATION
This 73-year-old male with 2–3 weeks of imbalance (more than dizziness) on standing/sitting shows:
-
Multi-canal BPPV — Both right posterior canal (positive Dix-Hallpike right) AND right/bilateral horizontal canal (positive McClure-Pagnini bilaterally with geotropic pattern). This is the most likely primary cause of his postural imbalance during namaz posture changes.
-
Reduced smooth pursuit (bilateral, asymmetric, involving vertical plane) + bidirectional gaze-evoked nystagmus without fixation — These are central oculomotor signs, raising concern for:
- Age-related cerebellar/brainstem degeneration (presbyvertigo component)
- Possible small vessel ischemic disease (common in elderly)
- Cannot exclude early central vestibular/cerebellar pathology
-
No spontaneous nystagmus, no unilateral canal paresis — argues against acute unilateral vestibular neuritis or Ménière's disease.
-
Mild SVV tilt — consistent with otolithic (utricular) dysfunction.
RECOMMENDED MANAGEMENT
Immediate:
- Canalith Repositioning Maneuver (CRM):
- Epley maneuver for right posterior canal BPPV
- Bárány/Gufoni maneuver for horizontal canal BPPV
- Falls prevention counseling (high-risk elderly patient)
Investigations:
- MRI brain with FLAIR — to assess for cerebellar/brainstem ischemic changes given central oculomotor findings
- Blood pressure monitoring (orthostatic hypotension can co-exist and worsen imbalance on standing)
- Blood glucose, CBC, lipid profile
Vestibular Rehabilitation:
- Gaze stabilization exercises
- Balance training (Cawthorne-Cooksey or supervised VRT)
Follow-up VNG after CRM to reassess BPPV resolution and pursue central workup if pursuit/gaze abnormalities persist.
Note: The caloric test (warm/cool water or air irrigation) was not performed in this study — its inclusion would better quantify any unilateral peripheral hypofunction. Clinical correlation with neurological examination is strongly advised given the central signs on this VNG.
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