Some people feel perfectly fine sitting at home, yet become dizzy, disoriented or unsteady as soon as they enter a busy supermarket, shopping centre or crowded environment.
Others notice similar symptoms while:
- driving;
- walking through patterned aisles;
- using escalators;
- watching traffic move past;
- scrolling quickly on a screen;
- walking through large open spaces; or
- turning their head while moving.
This can be confusing, especially if previous eye examinations, scans or vestibular tests have been described as “normal”.
One possible contributor is the way the visual and balance systems are interacting.
Why Can Busy Visual Environments Make Me Dizzy?
Your brain uses information from several systems to work out where you are in space.
These include:
- vision;
- the vestibular system in the inner ear;
- proprioception from your muscles and joints; and
- other sensory information about movement and position.
Normally, these systems work together automatically.
In a visually busy environment, however, the amount of visual movement entering the brain increases dramatically.
Imagine walking down a supermarket aisle.
Your eyes and brain are processing:
- shelves moving past you;
- repeating patterns;
- bright signs;
- other shoppers;
- trolley movement;
- head movement;
- changes in distance; and
- objects moving in your peripheral vision.
For some people, the visual system begins to contribute too much to their sense of balance.
This can produce dizziness, disorientation or a feeling that the environment is moving.
What Is Visual Motion Sensitivity?
Visual motion sensitivity refers to symptoms triggered by movement within the visual environment.
Common triggers include:
- supermarkets;
- shopping centres;
- crowds;
- escalators;
- patterned floors;
- fast-moving television;
- scrolling;
- traffic;
- walking beside moving vehicles; and
- looking out of a car window.
Patients may describe:
- dizziness;
- nausea;
- feeling “off balance”;
- a floating sensation;
- difficulty walking straight;
- headache;
- eye strain;
- blurred or unstable vision;
- anxiety in busy environments; or
- needing to leave the area.
The symptoms are real even when the eyes themselves appear structurally healthy.
Why Are Supermarkets Such a Common Trigger?
Supermarkets are almost a perfect visual stress test.
They contain:
- long rows of repeating patterns;
- strong peripheral visual stimulation;
- bright overhead lighting;
- multiple depths and distances;
- people moving in different directions; and
- continuous self-motion as you walk.
Your peripheral vision is constantly detecting movement.
If the brain is overly reliant on visual information for balance, this can create a mismatch between what the eyes are seeing and what the vestibular and body-position systems are reporting.
This mismatch can feel like dizziness or instability.
Why Can Driving Trigger Similar Symptoms?
Driving places very high demands on visual processing.
You are simultaneously monitoring:
- lane position;
- cars moving around you;
- road signs;
- mirrors;
- peripheral motion;
- changing distances;
- head movements; and
- speed.
Some patients feel worse:
- on motorways;
- in heavy traffic;
- driving at night;
- passing large trucks;
- driving through tunnels;
- going around bends; or
- travelling at higher speeds.
Interestingly, some people feel worse as a passenger than as the driver because they have less control over the movement.
Can Binocular Vision Problems Contribute?
They can in some patients.
Your two eyes need to work together accurately while you move through the environment.
If there is a binocular vision problem, your brain may need to expend additional effort keeping the two images aligned and stable.
Potential findings may include difficulties with:
- eye alignment;
- convergence;
- divergence;
- focusing;
- vertical eye alignment;
- eye movement control; or
- visual processing during movement.
This does not mean that every person who feels dizzy in a shopping centre has binocular vision dysfunction.
Dizziness has many possible causes.
However, binocular vision can be one part of the picture, particularly when symptoms are strongly visually triggered.
What About Vertical Heterophoria?
Some patients have a small vertical tendency for one eye to sit slightly higher than the other.
The brain usually compensates for this automatically using vertical fusion.
In some people, however, maintaining alignment may become more difficult or uncomfortable.
Symptoms can include:
- headaches;
- eye strain;
- dizziness;
- motion sensitivity;
- difficulty reading;
- discomfort in busy environments; or
- feeling better when one eye is closed.
Vertical alignment findings need to be interpreted carefully.
A small vertical phoria by itself does not prove that it is the cause of a patient’s dizziness.
The clinical question is whether the finding is repeatable, consistent with the symptoms and meaningfully changes function when treated.
Why Can My Standard Eye Test Be Normal?
A standard eye examination usually checks things such as:
- visual acuity;
- spectacle prescription;
- eye health;
- eye pressure; and
- basic eye alignment.
That is important, but it does not necessarily reproduce the demands of walking through a supermarket or driving on a motorway.
A person may have:
- 6/6 vision;
- healthy eyes;
- a small or insignificant spectacle prescription; and
- no obvious eye turn,
yet still struggle with visual motion, eye coordination or visual-vestibular integration.
This is one reason patients sometimes say:
“Every eye test says my eyes are fine, but busy places still make me dizzy.”
Could It Be a Vestibular Problem Instead?
Absolutely.
Dizziness can arise from many causes, including:
- inner-ear disorders;
- vestibular migraine;
- migraine-associated dizziness;
- neurological conditions;
- medication effects;
- cardiovascular problems;
- anxiety;
- post-concussion changes; and
- other medical conditions.
The visual and vestibular systems are closely connected.
For some patients, the primary problem is vestibular.
For others, visual dysfunction contributes.
And in many cases, both systems are involved.
This is why persistent or unexplained dizziness should not automatically be labelled as an eye problem.
Why Might Vestibular Therapy Not Completely Solve the Problem?
Vestibular rehabilitation can be very effective.
However, some patients continue to struggle with visually complex environments even after their general balance has improved.
If symptoms remain strongly triggered by:
- reading;
- screen use;
- patterned environments;
- shopping centres;
- driving;
- eye movements; or
- changes in visual focus,
it may be worth assessing whether the visual system is still contributing.
In some cases, optometric treatment and vestibular rehabilitation can complement each other.
What Happens During a Binocular Vision Assessment?
A more detailed visual assessment may investigate:
- eye alignment at distance and near;
- horizontal and vertical phorias;
- convergence;
- divergence;
- focusing ability;
- eye movement control;
- stereopsis;
- visual comfort;
- symptom triggers; and
- how the eyes respond to different visual demands.
The aim is not simply to find an abnormal measurement.
It is to determine whether the visual findings match the patient’s actual symptoms.
Can Prism Help?
Sometimes.
Prism lenses alter the direction of light entering the eyes and can reduce the amount of effort required to maintain binocular alignment.
For selected patients, prism may improve symptoms such as:
- visual strain;
- headaches;
- diplopia;
- motion sensitivity; or
- discomfort in visually busy environments.
However, prism is not a universal treatment for dizziness.
The amount and direction of prism need to be based on examination findings and the patient’s response.
Some patients benefit considerably.
Others notice little difference.
And inappropriate prism can sometimes make symptoms worse.
For this reason, prism should be prescribed cautiously rather than simply because a small phoria is measured.
Can Vision Therapy Help?
In selected cases, yes.
Vision therapy may be considered when symptoms are associated with deficits in areas such as:
- convergence;
- divergence;
- eye movement control;
- accommodative function; or
- binocular coordination.
For patients with post-concussion or visual-vestibular symptoms, treatment may also need to be coordinated with other practitioners such as:
- vestibular physiotherapists;
- neurologists;
- rehabilitation physicians; or
- occupational therapists.
The most appropriate approach depends on the underlying problem.
What About Migraine?
Migraine is particularly important because it can cause pronounced visual sensitivity even without a typical severe headache.
Patients may experience:
- light sensitivity;
- motion sensitivity;
- dizziness;
- difficulty with patterned environments;
- visual aura;
- nausea; or
- symptoms triggered by screens and fluorescent lighting.
If the symptoms suggest migraine or another neurological condition, medical assessment may be appropriate even if binocular vision findings are also present.
When Should I Seek Medical Assessment?
New or significant dizziness should be medically assessed, particularly if it is associated with:
- sudden onset;
- weakness or numbness;
- difficulty speaking;
- severe headache;
- new double vision;
- loss of vision;
- fainting;
- marked imbalance;
- hearing changes; or
- other neurological symptoms.
An optometric assessment should complement—not replace—appropriate medical investigation.
Why Do Some People Feel Better Closing One Eye?
Closing one eye removes the need for the brain to combine two visual images.
If binocular coordination is contributing to symptoms, some patients notice temporary relief when one eye is closed.
This can be a useful clue, but it does not establish a diagnosis on its own.
The same symptom can occur for several reasons and needs to be interpreted alongside the rest of the examination.
What If All My Tests Have Been Normal?
That is a common experience for patients with visually triggered dizziness.
Normal investigations are reassuring because they can help exclude serious conditions.
But “normal” does not necessarily mean that every aspect of visual function has been tested under the situations that provoke your symptoms.
If symptoms are consistently triggered by visual environments, a more detailed binocular and visual-motion assessment may identify whether the visual system is contributing.
Sometimes no significant optometric cause is found—and that information is also useful because it helps direct the investigation elsewhere.
Binocular Vision and Visual Dizziness Assessment in Sydney
At Westmead Eyes, we assess patients who experience symptoms such as:
- dizziness in supermarkets or shopping centres;
- discomfort while driving;
- visual motion sensitivity;
- headaches;
- eye strain;
- difficulty focusing;
- post-concussion visual symptoms; and
- persistent symptoms despite otherwise normal eye examinations.
The aim is not to assume that every case of dizziness is caused by the eyes.
It is to determine whether binocular vision or visual processing is contributing to the patient’s symptoms, and whether optometric treatment is appropriate.
Learn more about Binocular Vision Dysfunction and Visual Dizziness Here
If you experience persistent visually triggered dizziness, you can book a Binocular Vision Assessment for a more detailed evaluation.