Light cupula: the pathophysiological basis of persistent geotropic positional nystagmus

OBJECTIVE: To clarify the pathophysiological basis of persistent geotropic positional nystagmus (PGN) in patients with the horizontal canal type of benign paroxysmal positional vertigo (H-BPPV), the time constant (TC) of nystagmus and the relationship between its slow phase eye velocity (SPV) and the angle of head rotation in supine were defined. METHODS: Geotropic or apogeotropic positional nystagmus was recorded by video-oculography and analysed three-dimensionally. RESULTS: Geotropic positional nystagmuses in patients with H-BPPV were classified as transient geotropic positional nystagmus with a TC of ≤35 s or PGN with a TC of >35 s. Alternatively, the TC of persistent apogeotropic positional nystagmus (AN) in patients with H-BPPV was >35 s. The direction of the SPV of patients with PGN was opposite to that of patients with AN at each head position across the range of neutral head positions. The relationship between the SPV of patients with PGN and the angle of head rotation was linearly symmetrical against that of patients with AN with respect to a line drawn on the neutral head position. CONCLUSIONS: Since its TC was >35 s, it is suggested that PGN is induced by cupula deviation in response to gravity at each head position. It is also suggested that the direction of cupula deviation in patients with PGN is opposite to that of patients with AN across the neutral head positional range with no nystagmus where the long axis of cupula is in alignment with the axis of gravity. Since the pathophysiological basis of AN is considered a heavy cupula, it is suggested that PGN is conversely induced by a light cupula.