ICS Impulse USB. Reference Manual. Doc. No EN/01 Part No EN

Transcription

1 ICS Impulse USB Reference Manual Doc. No EN/01 Part No EN

2 Copyrightnotice Nopartof this documentation orprogram may be reproduced, stored ina retrieval system, ortransmitted, in anyform orby any means, electronic,mechanical,photocopying, recording,or otherwise,without the priorwritten consent ofgn Otometrics A/S. Copyright 2015, GN Otometrics A/S Publishedin Denmark bygn Otometrics A/S, Denmark Allinformation, illustrations, and specifications inthis manual are based on the latest productinformation available atthe time of publication. GN Otometrics A/Sreserves the right tomake changes atany time without notice. Registeredtrademarks and Trademarks MADSEN Itera II,MADSEN OTOflex 100, OTOsuite,AURICAL FreeFit, AURICAL Visible Speech, MADSEN Astera², MADSEN Xeta, ICS Chartr 200 VNG/ENG, ICSChartr EP, OTOcam 300,MADSEN AccuScreen, MADSEN AccuLink,ICS AirCal, AURICAL Aud, AURICAL HIT, ICS Impulse, OTObase and MADSEN Capella² are either registeredtrademarks ortrademarks ofgn Otometrics A/S. Versionrelease date Technicalsupport Please contact your supplier. 2 Otometrics - ICS Impulse USB

3 Table of Contents 1 Introduction Device description Intended Use Intended User About this manual ICS Impulse Safety Typographical conventions Navigating this manual 9 2 Getting Started System startup Logging in Presentation remote Understanding the OTOsuite Vestibular screen Switching between viewing modes Understanding the test selection window Selecting a test Adding remarks to a selected test Deleting a selected test Deleting videos Entering test remarks Patient data entry Current Patient group Temporary patient Patients group New Patient Existing Patient Logging out 24 3 Pre-testing setup Patient preparation Goggles preparation Cleaning and maintenance Replacing the strap Replacing the face cushion Goggles placement Vision-denied solution and goggles placement Preparing Attaching the right-eye cup Attaching the left-eye patch Verify light tightness Goggles placement over the vision-denied solution Removing the vision-denied cup and patch 32 4 Oculomotor Test environment Video recording eye movement during testing Pupil detection Calibration 35 Otometrics - ICS Impulse USB 3

4 4.5 Optimizing collection Gaze tests Collecting Gaze data Gaze data analysis Analysis window Analysis details Info Remarks Reanalysis Playback of data collection VOR tests Collecting VOR data VOR data analysis Analysis window Analysis details Info Remarks Playback of data collection Skew Deviation test Collecting Skew Deviation data Skew Deviation data analysis Analysis window Analysis details Info Remarks Playback of data collection 54 5 Head Impulse Test environment Pupil detection Lateral test LARP or RALP test Calibration Video recording eye movement during testing Optimizing collection Collecting Head Impulse data Monitoring eye and head movement Real Time Trace window Impulse window Head Impulse single-test data analysis Analysis details Gain Info Remarks Display Reanalysis D Analysis window Understanding the 2D analysis Hex Plot window D Analysis window Understanding the 3D analysis Head Impulse multiple-tests data analysis Progress Graphs 86 4 Otometrics - ICS Impulse USB

5 5.8.2 Progress Data 87 6 Positional Test environment Video recording eye movement during testing Pupil Detection Calibration Optimizing collection and treatment Dynamic tests Collecting Dynamic data Dynamic data analysis Analysis window Analysis details Info Remarks Reanalysis Playback of Data Collection Repositioning tests Collecting Repositioning data Repositioning data analysis Analysis window Analysis details Info Remarks Reanalysis Playback of Data Collection Video Record/Playback Record Playback Reports Edit Report Selecting items from report lists Customizing report lists Review Report Options Report toolbar buttons Patient Lists OTOsuite Vestibular Database Chartr Database Patient Export Patient Import Options General Graph Colors Oculomotor Head Impulse Positional Facility Info Report Options 139 Otometrics - ICS Impulse USB 5

6 11 System Settings Administrator Set up a new user Edit user data Delete user Workstation Settings OTOsuite Vestibular Database Archiving patient data Auto-Backup Preventing data loss (standalone installations) GDT Interface About Software license Goggles firmware Error Logs Software Procedures Installation and Setup Minimum computer requirements Presentation remote - compatible models Software Installation Start installation Choose installation type Server/Both installation Client installation Complete the installation Connecting the goggles Installing the synchronized room video Setting up an external monitor Importing sample report lists Importing demo data Customizing for your facility Installing Adobe Reader Changing the storage locations for videos, export, import, report PDFs Uninstalling Upgrading Reinstalling Troubleshooting ICS Impulse System Safety Symbols used Label locations Safety notes Manufacturer Responsibility of the Manufacturer Technical Specifications ICS Impulse System Accessories Guidance and manufacturer s declaration tables Otometrics - ICS Impulse USB

7 App. 1 Calibration algorithm 174 App. 2 Head Impulse Collection and Analysis algorithms 175 App. 3 Understanding raw data files 176 App. 4 Using raw data to calculate latency 178 App. 5 Approximating position data 180 App. 6 Set power options 182 App. 7 SPV Algorithm 184 Index 185 Otometrics - ICS Impulse USB 7

8 1 Introduction 1 Introduction Congratulations! You are now the owner of a sophisticated new ICS Impulse system developed in collaboration with Drs. Ian Curthoys, Michael Halmagyi and others at University of Sydney. To assist you in getting the most out of the ICS Impulse system, we have included a user guide, online reference manual and a training video. We hope you find it easy to use and that your use of the incorporated tips and information results in improved data collection accuracy as it relates to your assessment of vestibular-related disorders, test results, reporting, and patient information retrieval. 1.1 Device description ICS Impulse is a monocular video goggles with built-in 9-axis motion tracking sensor that allows for the measurement of eye and head movement. The ICS Impulse is operated from the OTOsuite Vestibular software. Note The Oculomotor and Positional modules are pending FDA clearance and are not available in the United States. 1.2 Intended Use The ICS Impulse System is used in the assessment of the vestibular-ocular reflex (VOR) and nystagmus by measuring, recording, displaying, and analyzing eye and head movements. Note The ICS Impulse System is intended to be used only by qualified medical personnel. 1.3 Intended User This manual describes the use of the device in combination with the software. Readers are assumed to have prior knowledge of the medical and scientific facts underlying the procedure. For this reason, the examination methods are mentioned only to the degree that is necessary for a correct, safe application of the ICS Impulse System. You can find more information in the ICS Impulse training video or at Learn about the research behind ICS Impulse on About this manual This is your guide to using the basic functions required for navigating in OTOsuite Vestibular and the various OTOsuite Vestibular modules. This includes key features such as printing test results, handling patient and user administration, and data and test device management. Training It is recommended that you make yourself familiar with the features provided by OTOsuite Vestibular and the test device before testing a patient. 8 Otometrics - ICS Impulse USB

9 1 Introduction ICS Impulse Safety This manual contains information and cautions which must be followed to ensure the safe performance of the ICS Impulse System. Caution Local government rules and regulations, if applicable, should be followed at all times. Safety information is stated where it is relevant, and general safety aspects are described in ICS Impulse System Safety Typographical conventions The use of Warning, Caution and Note To draw your attention to information regarding safe and appropriate use of the device or software, the manual uses precautionary statements as follows: Warning Indicates that there is a risk of death or serious injury to the user or patient. Caution Indicates that there is a risk of injury to the user or patient or risk of damage to data or the device. Note Indicates that you should take special notice Navigating this manual Window tabs, icons and functions to select are shown in bold type, as for instance in: Click Save Otometrics - ICS Impulse USB 9

10 2 Getting Started 2 Getting Started 2.1 System startup 1. Switch on the computer. 2. Double-click the OTOsuite Vestibular icon. Note To extend the life of the components in the goggles, it is best to close the software when not in use. If the software is left open, the fan will continue to run and cool the goggles. 2.2 Logging in Note An Administrator user name and password are provided with a new installation of OTOsuite Vestibular. DO NOT delete the user name or password from the login screen until at least one new user name with password has been added. Ensure that at least one user has administrator privileges. For information on how to add new users, refer to Set up a new user 141. At the login screen Note The password is case sensitive. 1. Enter your user name. 2. Enter your password and click OK. 10 Otometrics - ICS Impulse USB

11 2 Getting Started 2.3 Presentation remote The presentation remote provides an alternative method for some test functions: To start a test Press the left button To stop a test Press the right button To mark the trace for the Skew Deviation test When using Head Position Feedback Press the left button to indicate the eye is covered Press the left button to indicate the eye is not covered Press the left button instead of clicking Center For more information about the presentation remote, refer to Presentation remote - compatible models Understanding the OTOsuite Vestibular screen Otometrics - ICS Impulse USB 11

12 2 Getting Started Navigation panel A - Information about the current patient. B - Items grouped into a set of menus. Refer to Navigation Panel and Startup Module 13 to understand how to customize the navigation panel display. Note An overview of available data is displayed when a patient has been selected and opened: Previously collected data for the patient is indicated by a checkmark next to each test type name. C - Button for access to the Reference Manual. Status bar Tabbed windows Button to hide or show Navigation panel (D), Logout button (E), current operator (F), system status (G), current date (H), and current time (I). When OTOsuite Vestibular is opened, the selected startup module is open and ready for use. To understand how to change the startup module to a different test type as well as how open additional test types, refer to Navigation Panel and Startup Module 13. Clicking an item from one of the menus in the navigation panel opens the window or set of windows of the associated with that item. For example, clicking Impulse from the Head Impulse menu group opens the set of windows (J) for the Impulse test. The active window is the data collection window. The set of additional windows allow for the review and comparison of data results. The top level tabs correlate to the menu group(s) from which an item has been opened. In this example, the top level tab is Head Impulse (K). Clicking on a tab that correlates with a menu group, makes the most recently accessed item from that group active. To open an additional item from the same menu group, click on the item in the navigation panel. 12 Otometrics - ICS Impulse USB

13 2 Getting Started Navigation Panel and Startup Module The license in the goggles determines which test group menus (for example, Oculomotor, Head Impulse, etc.) are open the first time the OTOsuite Vestibular is started. The default startup module, Video Record/Playback, is open and ready to use. Click to open or to close a test group menu. When the software is restarted, the test groups remain as set in the previous session. To change which test type is set as the startup module, from the Options menu, click Test Options. This opens the General window in which you can select a test type from the Startup Module list. To perform a test if the module is not currently open, click on the test type name. The data collection window and all associated tabs open. Resizing screen areas Note If a thick blue bar separates an area of the screen, the size of the areas can be changed. For example, to increase the width of the navigation panel, position the cursor over the blue bar until a double-headed arrow appears (A). Click the left mouse button and drag the bar to a new location. These bars separate windows vertically as shown here but can also separate windows horizontally. Otometrics - ICS Impulse USB 13

14 2 Getting Started 2.5 Switching between viewing modes By default test results for all tests (Oculomotor, Head Impulse, and Positional) display in equally sized windows (normal viewing mode). 14 Otometrics - ICS Impulse USB

15 2 Getting Started To enlarge one window within the group, click the small box in the top right corner of that window. Head Impulse, 2D Analysis example of normal viewing mode showing small box (A) To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. Head Impulse, 2D Analysis example of enlarged viewing mode showing two overlapping boxes (B) Otometrics - ICS Impulse USB 15

16 2 Getting Started Note Windows open in the normal viewing mode when OTOsuite Vestibular is restarted. 2.6 Understanding the test selection window In this window you can view the list of tests for a patient. Clicking on the column headings allows you to reorder the tests for ease of finding a specific test. Remarks can be added to a specific test Selecting a test To view a specific test, click on the Test window tab and then click the desired test to highlight it. To make it easier to locate a specific test, click one of the column headings. For example Click the Date & Time column heading (A) to change the order from ascending order (older to more recent) to descending order (more recent to older). Click the Remarks column (B) to change the order from ascending order (A to Z) to descending order (Z to A) Adding remarks to a selected test For more information about selecting a test, refer to Selecting a test 16.For more information about test remarks, refer to Entering test remarks 19. With the test selected, add remarks in the Remarks column of the Test window, or click on the Remarks tab. The Remarks window includes editing tools. Remarks are visible in both the Test and Remarks windows. To mark a test for a specific purpose (for example, to indicate abnormal results), click in the check box under the column heading marked with the unique identifier symbol:. Note The status of the Vision Denied check box is set when performing the test. It is not possible to change the status in the test selection window. 16 Otometrics - ICS Impulse USB

17 2 Getting Started Deleting a selected test Depending on the test type, to delete a selected test, click Delete Test. For more information about selecting a test, refer to Selecting a test 16. Caution If you choose to delete a selected test and click Yes at the prompt, the test data is permanently deleted. There is no possibility to retrieve the test Deleting videos It is recommended to delete videos that are not needed in order to save disk drive space. After a video(s) has been deleted, the video data cannot be recovered. Depending on the test type, there may be only a video of the eye or there may also be a room video. If the test includes both an eye video and a room video, it is not possible to delete only the eye video or only the room video. Oculomotor and Positional videos To delete the video(s) for a selected test, click Delete Video. For more information about selecting a test, refer to Selecting a test 16. Otometrics - ICS Impulse USB 17

18 2 Getting Started Head Impulse and Video Record/Playback videos To delete the video(s), from the Videos menu, click Video Record/Playback. Click Playback. If the test is not highlighted, click the desired test to select it. Click Delete Video. Caution Clicking Delete Video will delete all videos associated with that test. If you choose to delete the video(s) for the selected test and click Yes at the prompt(s), the video data is permanently deleted. There is no possibility to retrieve the video data. 18 Otometrics - ICS Impulse USB

19 2 Getting Started 2.7 Entering test remarks Test remarks are added in the Remarks window that includes editing tools. Remarks window (Head Impulse) Cut selected text Copy selected text Paste text that was cut or copied Apply bold formatting Apply italic formatting Apply underline formatting Undo actions (text entry, text formatting, etc.) starting with the most recent action and proceeding in reverse order of actions done. Reverse an undo action starting with the most recent undo and proceeding in reverse order of undo actions. Remarks added during testing are saved according to the test type and session and can be viewed and edited in the Remarks window of the selected test. Editing remarks Remarks are visible in both the Test and Remarks windows. Remarks can be edited in the Remarks window of the selected test. In the Remarks column of the Test window, text can be added and text can be deleted. Remarks in the Review Report Options window Test remarks added during analysis can be viewed in the Review Report Options window. Remarks viewed in this window cannot be edited. Otometrics - ICS Impulse USB 19

20 2 Getting Started 2.8 Patient data entry Current Patient group The Current Patient group provides information about the patient currently open. Click Edit to modify patient information Click Close to close the current patient and start a new temporary patient Temporary patient If no patient is open, a temporary patient is available. The temporary patient allows testing to start without entering patient data. The patient is given a unique number based on the date and time the patient record was created (yyyymmddhhmmss where yyyy=year, mm=month, hh=hour, dd-day, mm=minute, and ss=second). Once data is saved, you will be prompted to edit the temporary patient information. For information about editing existing patient information, refer to Existing Patient Patients group This group allows you to create a new patient or view a list of existing patients New Patient To enter information for a new patient, click New Patient and add patient information in the form: 20 Otometrics - ICS Impulse USB

21 2 Getting Started Entries that cannot be left blank are marked with an asterisk (*). For all entries the maximum number of characters is 45. Patient ID can be numeric, alphabetical or a combination of numbers and letters. To set the gender, click the down arrow and select the appropriate entry. The date of birth format is determined by the computer setup and will display as mm/dd/yyyy or dd/mm/yyyy where mm=month, dd=day, and yyyy=year. Only numeric characters are allowed (alpha characters can not be used). Note The patient's birth date is required to determine the age-based normative data to be used for head impulse gains for that patient. Click Cancel to close the form without saving any changes. Click Save to save the data. Note The system alerts you with a message with the first occurrence of a required entry that is blank. Otometrics - ICS Impulse USB 21

22 2 Getting Started Existing Patient Note A complete description of patient list operations is provided in Patient Lists 124. From the Patients group, click Patient List. The window that displays provides access to existing patients. Each row has patient information separated into columns according to the type of information such as the patient name and identification number. The following rows are searchable: last name, first name, patient ID, Gender, DOB, and Physician. To search start typing in the row between the title and the first patient entry. Clear search field by clicking the clear button. The tests collected for an existing patient are indicated by a checkmark in the appropriate test column: Oculomotor Head impulse Positional Videos Note The unique identifier symbol ( ) indicates the user has chosen to mark one or more tests or videos for a specific purpose (for example, it may refer to abnormal results, results to be used for a study, etc.) 22 Otometrics - ICS Impulse USB

23 2 Getting Started To select a patient, click the patient name. Buttons at the bottom of the patient list allow you to open and edit the patient file: Click Open (or double-click) to open the patient to view test results. Previously collected data for the patient is indicated by a checkmark next to each test type name. Otometrics - ICS Impulse USB 23

24 2 Getting Started Click Edit to make changes to the existing patient information. Modify patient information in this form: Entries that cannot be left blank are marked with an asterisk (*). Note The patient's birth date is required to determine the age-based normative data to be used for head impulse gains for that patient. 2.9 Logging out To log out, click Logout (A) in the lower left corner of the screen. 24 Otometrics - ICS Impulse USB

25 3 Pre-testing setup 3 Pre-testing setup 3.1 Patient preparation Warning A head impulse should not be performed on patients with a neck injury, or on patients who have been told by their physicians to limit or avoid neck movement activity. Prior to testing, provide the patient with these general recommendations: If in doubt, consult with a physician about the possible side effects of stopping a particular medication. Stop tranquilizers, sedatives, or vestibular suppressants for at least 48 hours before the test. Continue medications that are vital, such as insulin, heart medications, seizure medications, and possibly antidepressants. No alcohol for 48 hours before testing. Do not wear make-up around the eyes. Wear comfortable clothing. 3.2 Goggles preparation Cleaning and maintenance The ICS Impulse goggles do not require preventive maintenance. Observe the following recommended guidelines regarding cleaning and maintenance. Keep the lens cover on the camera when goggles are not in use. Keep the instrument clean and as free of dust as possible. Remove dust using a soft cloth. If required, clean the goggles housing using a damp cloth moistened with a mild detergent and water solution. Do not allow any moisture to get inside the goggles. Keep moisture away from the cooling fan. Caution Never spray or immerse the goggles components with cleaning solutions. This could contaminate the electronics and/or optics. If required, clean the mirror and/or the camera lens using the supplied cleaning cloth. The presence of fingerprints on the mirror surfaces could cause inaccurate pupil detection. If the camera or mirror is not clean, artifacts will be seen during data collection. Caution Improper cleaning of either the mirror or the camera lens may scratch the surfaces. Caution A small cooling fan is inside the goggles housing. Keep the fan blades free from any obstruction. Otometrics - ICS Impulse USB 25

26 3 Pre-testing setup Replace the strap as required. Refer to Replacing the strap Replacing the strap 1. Remove the face cushion. 2. Use a pen to push the plastic clip down and pull out the strap clip attached to the goggles. 3. Repeat on the other side. 4. Remove the cable from both clips on the strap. 5. Obtain a new strap assembly 6. Clip the strap clips into each side of the goggles. 7. Attach the cable to both clips on the strap Replacing the face cushion Note The single-use, disposable face cushion should be replaced for each new patient. 1. To remove the face cushion, slightly flex the goggles out at the side opposite of the camera side and snap out the face cushion. Release the face cushion from the other side. 2. Properly dispose of the used face cushion. 3. Obtain a new face cushion. 4. Align the tab of the face cushion with the hole on the camera side of the goggles. 5. Ensure the face cushion is inside the nose piece. 6. Slightly flex the goggles at the opposite side, align the tab of the face cushion with the hole on this side of the goggles. 7. Double check both sides are fully inserted by pressing in at each side. 26 Otometrics - ICS Impulse USB

27 3 Pre-testing setup 3.3 Goggles placement When goggles are placed properly they sit comfortably on the bridge of the nose and will not slip during the test. Caution Goggles fit is Important. Improper goggles fit can result in inaccurate data collection. Goggles slippage often results in inaccurate gain values (too high). Note You can find more information in the ICS Impulse training video or at After placing the goggles on the patient and tightening the strap, look at how the goggles fit on the person's face. If there are gaps between the goggles and the patient's face the goggles may slip. Improper goggles fit 1. Before putting the goggles on the patient ensure the goggles have a new unused face cushion. Refer to Replacing the face cushion 26. the mirror is clean. Refer to Goggles preparation 25. Note The single-use, disposable face cushion must be replaced for each new patient. Caution Improper cleaning may scratch the mirror surfaces. 2. If required, replace the strap. Refer to Replacing the strap Position the goggles on the patient s face over the bridge of the nose. 4. Bring the strap above the patient s ears and around to the back of head. 5. Tighten the strap tight enough to ensure that goggles will not shift during testing. Otometrics - ICS Impulse USB 27

28 3 Pre-testing setup 6. Allowing some flexibility in the cables for head movement during testing, clip the cable clip to the patient s clothing at the top of the patient's right shoulder. 7. Ensure the eyes are wide open with eyelids positioned to not interfere with pupil detection. If required, adjust the skin around the eye: Tilt the bottom of the goggles out and away from the face, pulling the skin below the eye down and repositioning the goggles to hold the skin in place. Tilt the top of the goggles out and away from the face, pulling the skin above the eye up and repositioning the goggles to hold the skin in place. 8. Visually inspect the goggles fit. Proper goggles fit 28 Otometrics - ICS Impulse USB

29 3 Pre-testing setup 3.4 Vision-denied solution and goggles placement Preparing 1. Do not test in a room with complete darkness. While it may NOT seem intuitive, for optimal results some ambient room light is beneficial for obtaining a completely light tight test environment for the patient. 2. For patients with long eyelashes, it is advised to remove any mascara. Mascara deposited on the inside of the black window of the right eye cup (through which the pupil is tracked and the eye is recorded) adversely affects both pupil tracking and recording of the eye. Important DO NOT TOUCH THE BLACK WINDOW When handling the right-eye cup, do not touch the black window. Oils in the skin reduce the effectiveness of the anti-fog coating on the window. Fingerprints make it difficult to track the pupil. 3. Obtain a vision-denied solution (includes a cup for the right eye and a patch for the left eye). Caution The single-use, disposable vision-denied solution should be replaced for each new patient and should not be cleaned and reused. 4. Inform the patient that they will be in complete darkness for a short period. Assure them that, while they cannot see out, the camera in the goggles can still record their eye movement. Otometrics - ICS Impulse USB 29

30 3 Pre-testing setup Attaching the right-eye cup 1. Remove the plastic backing from the back side of the cup. 2. Ask the patient to open their eye wide. Note It is easiest to position the cup if you and the patient are sitting at the same level instead of standing over the patient. 3. Ask the patient to stare straight ahead. You want the pupil to be in the center of the black window. 4. If the patient s eyelid droops, hold the eyelid up when placing the cup. This will assist in keeping the patient s eye wide open during testing. 5. Fold back the inside edge of the cup placing the ridge against the right side of the nose. A. Ridge B. Fold back the inside edge 6. Make sure the cup is centered over the eye (not angled up or down). Important DO NOT TOUCH THE BLACK WINDOW When handling the right-eye cup, do not touch the black window. Oils in the skin reduce the effectiveness of the anti-fog coating on the window. Fingerprints make it difficult to track the pupil. 7. Press gently around the edges to make sure that a seal has formed all the way around. Make sure that the cup is light tight Attaching the left-eye patch 1. Remove the plastic backing from the back side of the patch. 2. Ask the patient to close their eye. 3. Position the patch with the wider side toward the nose. Make sure the patch is centered over the eye (not angled up or down). 4. Press gently around the edges to make sure that a seal has formed all the way around. Make sure that the patch is light tight. 30 Otometrics - ICS Impulse USB

31 3 Pre-testing setup Verify light tightness 1. Give the patient a couple of minutes for the eyes to adjust. 2. Ask the patient if they can see any visible light. Do NOT have the patient look directly at a light bulb (spot light, halogen, incandescent). 3. With the vision-denied cup and patch attached well, and the patient unable to detect light, proceed with placing the goggles on the patient Goggles placement over the vision-denied solution Note Before placing the goggles over the vision-denied solution, make sure the goggles have a new unused face cushion. 1. In the OTOsuite Vestibular software, open a test from either the Oculomotor or Positional test group, or, from the Videos test group, open Video Record/Playback. 2. Position the goggles on the patient with the cup centered inside the goggles. 3. Tighten the strap so that the goggles stay on the patient during the testing but the goggles do NOT have to be as tight as needed for head impulse testing. Note The strap only has to be tight enough for the goggles to stay on during testing (spontaneous nystagmus, gaze, positional). You do not want to tighten the strap as tight as you would for head impulse testing. A strap that is too tight pushes the vision-denied solution into the face causing discomfort which makes recording of eye movement more difficult. 4. Check that the eye is centered inside the window of the cup. A. Not centered vertically: Should see more of the eyelid above the eye. B. Not centered vertically: Should see less of the area below the eye. C. Not centered horizontally: Inner edge of cup is not close enough to the nose. Notice the corner of the eye at the edge of the cup. Otometrics - ICS Impulse USB 31

32 3 Pre-testing setup Removing the vision-denied cup and patch Note Slowly removing the vision-denied cup and patch is much more comfortable than quickly removing them. 1. Ask the patient to close their eyes. 2. SLOWLY pull the cup and patch off of the patient s face. 32 Otometrics - ICS Impulse USB

33 4 Oculomotor 4 Oculomotor Note The Oculomotor and Positional modules are pending FDA clearance and are not available in the United States. 4.1 Test environment The environment can vary but must allow you to position the patient at least one meter from the wall (or other solid surface that can be used as a projection surface). This position will be utilized for calibration and for VOR testing. For Gaze (Gaze and Spontaneous) and Skew Deviation testing, the patient only needs to be positioned comfortably either sitting or in a supine position with the head at a 30 angle. For Calibration and Test Purposes: Note The patient should be seated in a chair that is stationary and does not swivel. 1. Choose a wall that allows you to position the patient at least one meter in front of the fixation dot. 2. Apply one of the fixation dots supplied with the system to the wall in a location that allows you to position the patient directly in front of the fixation dot. 4.2 Video recording eye movement during testing The Video window displays the image of the eye. The Auto-Record (A) is checked by default. The video recording of the eye and data collection start at the same time. Otometrics - ICS Impulse USB 33

34 4 Oculomotor 4.3 Pupil detection If using goggles only, refer to Goggles placement 27 for placement instructions. If using the vision-denied solution, refer to Vision-denied solution and goggles placement 29 for placement instructions. 1. Select the test: Gaze, VOR, or Skew Deviation. 2. Select the test type. For example, there are two test types for the Gaze test: Gaze and Spontaneous. 3. Select the test manuever. For example, there are five maneuvers for the Gaze test: Left, Right, Up, Down, and Center (A). 4. If using the vision-denied solution, select the check box Vision Denied. 5. Position the patient at least one meter in front of the wall. (Refer to Test environment 55 for information.) 6. Position the ROI (Region of Interest) around the pupil: click on the green box and drag to center it on the pupil, or click on the pupil to center the pupil inside the green box. Note For Head Impulse and VOR tests the ROI box is 100 x 100 pixels with a maximum sampling rate of 250 fps. For all other tests the ROI box is 160 x 120 pixels with a maximum sampling rate of 173 fps. 34 Otometrics - ICS Impulse USB

35 4 Oculomotor 7. In the Video window, choose the type of image displayed: Grayscale Image (A) or Pupil Location (B). Note The choice of Grayscale Image or Pupil Location is only used for setting the pupil detection. Eye video is always recorded in grayscale. 8. If the pupil was not automatically detected, select Auto-Threshold. The system centers the cross-hair on the pupil. 9. Ask the patient to stare at the fixation dot. Assess pupil tracking by observing the cross-hair. If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), use the + or button of the threshold slider to adjust. Pupil detection ensures that the system tracks the pupil properly during calibration and when collecting data. Note When Image Display is set to Pupil Location, make additional adjustments to remove any white areas outside the white circular image of the pupil. 10. Select OK to accept the ROI position. 11. Continue to Calibration Calibration Caution During this procedure both lasers will turn on. Do not look directly at the lasers. Use of controls or adjustments, or performance of procedures other than those specified herein, may result in hazardous radiation exposure. Otometrics - ICS Impulse USB 35

36 4 Oculomotor 1. Click Lasers On to turn on both lasers. 2. Ask the patient to position the left and right dots equidistant on each side of the fixation dot. 3. Ask the patient to look at the left dot, then at the right dot. In the Video window, check that the cross-hair continues to track the pupil. Note Use the Real Time Traces window to monitor head and eye data. By observing the orange head trace and the green eye trace, you can tell if the patient is moving their head or eyes (instead of staring at the fixation dot), blinking excessively, or not following instructions being given (not cooperating). 4. If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), use the + or button of the threshold slider to adjust. In the calibration procedure, the patient is asked to switch their gaze between the two dots that appear when the lasers are on. As the patient s gaze switches, the system tracks the movement of the pupil. Note When a patient cannot be calibrated (for example the vision is so poor that the patient cannot see the fixation dot or laser beams dots), click Default to use the calibration default value ( = 21). The eye movement between the two laser beam dots is measured and calibrated against the known values the laser beam dots projected from the goggles. The calibration values relate to the pixel location that equates to 7.5 degrees 36 Otometrics - ICS Impulse USB

37 4 Oculomotor left and right of center. The difference between the left and right equates to the number of pixels for a 15 degree movement of the eye. These values are used to analyze eye movement during the impulse testing. Refer to Calibration algorithm 174 for additional information. 5. Click Run. 6. Ask the patient to face the fixation dot and hold their head still. 7. Ask the patient to follow the laser beam dot. Note The calibration values are automatically saved. The stored calibration value can be used for all tests. There is no need to recalibrate between tests unless the goggles have moved. If you exit out of the patient s file and reopen, calibration will need to be performed again. Calibration check 1. Ask the patient to stare at the fixation dot and move the head side to side through a small angle (about 10 degrees). 2. Check that the eye and head velocities match. Good calibration - Eye and head velocities match Otometrics - ICS Impulse USB 37

38 4 Oculomotor (Examples of poor calibration show a calibration performed in Head Impulse) Poor calibration - Eye velocity is too low Poor calibration - Eye velocity is too high 38 Otometrics - ICS Impulse USB

39 4 Oculomotor 3. If the eye and head velocities do not match, you need to recalibrate or review the patient s history. Note If the patient has to make catch-up saccades during low frequency head rotations, this can indicate either vestibular loss, or cerebellar dysfunction, or both. When test results include catch-up saccades during low frequency head rotations, it is recommended that the Impulse test results be interpreted with caution. Data NOT within normal limits could be related to a peripheral and/or central disorder. Use the VOR tests to assess a patient with catch-up saccades during calibration check. 4. Once the calibration has been checked and you are satisfied with the result, click Accept. The Collection window opens and the software is ready to begin collecting head impulse data. Caution Once calibration has been performed, it is recommended not to reposition the goggles on the patient s head. 4.5 Optimizing collection This application provides these features to ensure good data collection: External Monitor You have the option to display a larger image of the eye on an external monitor. If an external monitor is connected to the computer, position the monitor where you can easily see the eye video. To display the eye video on the computer monitor as well as on an external monitor, click. The external monitor displays the real time SPV value for SPV tests. Note The external monitor is not supported for head impulse testing. Head Position Feedback For SPV tests, the Head Position Feedback option is the default setting. When set to this option, a reference graphic Otometrics - ICS Impulse USB 39

40 4 Oculomotor 4.6 Gaze tests of the patient's head position in real time displays on the computer monitor. (Refer to Oculomotor 133 to set the Head Position Feedback option.) In these tests, the goggles collect horizontal and vertical eye position data. The high speed camera captures the image of the eye. The OTOsuite Vestibular software processes the eye position data and calculates the slow-phase velocity (SPV). Gaze tests provide the ability to assess for gaze and spontaneous nystagmus. The purpose of these two test types is to identify nystagmus that is evoked without stimulus by having the patient stare at certain positions. The patient is typically in a sitting position or in the caloric position (head inclined 30 ). Gaze This test type assesses the patient s eye movement when the eyes are fixated in different directions (left, right, up, down and center). The person assessing the patient will provide the stimulus at which the patient is to stare. This stimulus can be the tester s finger, an implement (for example, the tip of pen or bobby pin) or the laser light presented on a wall from a presentation remote. Or, as in the case of vision-denied testing, the patient can be verbally instructed to look into the chosen direction. According to the ANSI standard, the eyes should be recorded for a minimum of 10 seconds with the eyes positioned at 30 from center, right and left as well as 25 from center for up and down. In order to assess for alternating or direction changing nystagmus the eyes should be recorded for more than 2 minutes. Please be aware that having the patient look further than the degrees stated above can result in end-point nystagmus which is not diagnostically relevant. The Gaze test may be performed with vision or with vision denied. Spontaneous This test type assesses the patient s eye movement when the eyes are in the primary position looking straight ahead without any visual stimulus. According to the ANSI standard, the eyes should be recorded for a minimum of 20 seconds. The patient or patient's head may be in various conditions such as sitting, supine, chin to chest or head extended backward. The Spontaneous test may be performed with vision or with vision denied. 4.7 Collecting Gaze data Note The temporary patient is available to allow testing to start without entering any patient data. Refer to Patient data entry 20 to create a new patient or open an existing patient. When collecting data, you can monitor head movement using the Head Position Feedback display or Synchronized Room Video. You can also choose to not use either.(the default display is set in Test Options.) 40 Otometrics - ICS Impulse USB

41 4 Oculomotor 1. This step applies only when monitoring the head movement during collection: Note Clicking Center sets the reference point used to provide feedback for head position during testing. The button is disabled if Head Position Feedback is not selected in the Test Options. For information about changing settings, please refer to Options 128. If using Head Position Feedback, position the patient's head before starting to collect data. Ensure that the patient's head is not moving and that it is perfectly centered. Click Center or press the left button on the presentation remote. If using Synchronized Room Video, you may need to adjust the camera position to ensure the entire head of the patient is seen in the video during data collection. 2. Instruct the patient. (For example, tell them to keep the eyes open and stare toward the left at your finger.) 3. To begin data collection, click Start or click the left button on the presentation remote. Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. (The default display is set in Test Options.) The real time SPV (slow-phase velocity) value is an estimated value calculated according to the amount of variability around the SPV estimate. The value is displayed in either green or orange in the upper right area of the window. Green: When the variability is low, there is a high probability that the value is reliable. Orange: When the variability is high, there is less probability that the value is reliable. Note SPV values displayed in orange should be considered less reliable but not inaccurate. Note You can find more information in the ICS Impulse training video or at Otometrics - ICS Impulse USB 41

42 4 Oculomotor Displayed in the Collection window are: Test Type name of test for which data has been collected (The name includes the test direction and the test conditions.) Elapsed Time duration of the test (Also, the test date and time is displayed). Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A. Test Type B. Elapsed Time C. Frame Rate D. Calibration The system automatically stops when the maximum test duration is reached. To stop the test early, click Stop or press the right button on the presentation remote. Data will be saved. To stop the test early, without saving data, click Cancel. (The maximum test duration is set in Test Options.) The data is analyzed and displayed in the Analysis window. 4.8 Gaze data analysis To view a specific test, click on the Test window tab and then click the desired test to highlight it. For more information about selecting the test, refer to Selecting a test 16. Analysis of the test results can be viewed in the Analysis window. To enlarge one window within the group, click the small box in the top right corner of that window. To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. For more information about switching between viewing modes (normal mode or enlarged mode), refer to Switching between viewing modes Analysis window Eye Position Traces Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. You can choose to display or not display a trace by clicking the check box in the trace legend.(the default display is set in Test Options.) 42 Otometrics - ICS Impulse USB

43 4 Oculomotor The traces are displayed with the culmination phase (area with the most robust response) centered in the middle of the window. To view an entire trace use the scroll bar below the trace. The report prints the part of the trace seen in the Traces window centered around the cursor. To choose when analysis begins, refer to Reanalysis 45. Slow Phase Velocity graph The purpose of this graph is to provide a record of the strength of the nystagmus. This graph displays the individual nystagmus beats identified by the SPV algorithm for the horizontal right (HR) and vertical right (VR) traces. The SPV peak is indicated in the graph by a square. To select a particular beat click on it or use the left/right arrow keys to move between beats. The SPV value for the beat is displayed whenever the mouse is positioned over the beat (A) and in the Info window (B). Refer to SPV Algorithm 184 for information about how the SPV peak is determined. If the algorithm did not pick a peak, manually set the peak for that trace. Refer to Reanalysis 45. Otometrics - ICS Impulse USB 43

44 4 Oculomotor Analysis details Info The test parameters are listed: Test Type name of test for which data has been collected Operator the person who was logged into OTOSuite Vestibular software when the data was collected Calibration the distance in pixels between the right and left eye positions measured during calibration Test Time date and time data collection was started Elapsed Time duration of the test Begin Time time at which analysis began Beat SPV the slow phase velocity for the selected beat Peak SPV where the slow phase velocity peak is set (For more information, refer to SPV Algorithm 184.) Remarks Remarks regarding the test can be entered before, during, and after testing. To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Note Text previously added in the Test window appears in the Remarks window. 44 Otometrics - ICS Impulse USB

45 4 Oculomotor Reanalysis Analysis Begin Time - All Traces To exclude data in a trace from the analysis: 1. Move the black cursor to the new begin time in the Eye Position Traces window. 2. In the Analysis Details window, click the Reanalysis window tab. 3. To reanalyze, click Reanalyze from Cursor - analyzes all traces with the begin time set to the next full second following the cursor position Reanalyze Full Trace - analyzes all traces from the beginning Note The begin time is displayed in the Info window. SPV Graph Select the trace to modify by choosing HR or VR Delete Beat - excludes the beat from the analysis and on the report Restore Beats - restores all beats that were manually deleted Select Peak click a beat and then select peak. A new peak will be set. See SPV Algorithm 184 for more details on peak determination. Restore Peak restores the peak to the location determined by the algorithm Playback of data collection The eye position traces and the eye video can be played back synchronously with the head position feedback or the room video recorded during testing. Video Playback buttons and selections Play Plays the video Otometrics - ICS Impulse USB 45

46 4 Oculomotor Video Playback buttons and selections Pause Stop Play from Cursor Speed Pauses the video Stops the video Select to start the playback at the position of the cursor. If not selected, playback starts at the beginning of the trace. Note Before setting the playback speed, check the recorded frame rate (fps) stated below the eye video. Normal - eye video recorded at 30 frames per second can only be played back at normal speed. Slow - eye video recorded at 60 frames per second can be played back at normal or slow speed. Slower - eye video recorded at > 60 frames per second can be played back at normal, slow, or slower speed. 4.9 VOR tests In these tests, the goggles collect both head and eye data. The gyroscope measures the velocity of the head movement (the stimulus). The high speed camera captures the image of the eye. The OTOsuite Vestibular software processes the eye and head velocity data (the response). Simultaneous displays of the data for head movement and for eye movement allow the clinician to determine if the response is within normal limits or not. The VOR tests provide the ability to assess the vestibulo-ocular reflex (VOR) with visual enhancement and without visual enhancement. The purpose of these two test types is to identify if catch-up saccades are present in either test condition. The patient is in a sitting position 1 meter from the wall where the fixation target is fixed and the suppression target is projected. VVOR (Visual VOR) This test type assesses the patient s vestibulo-ocular reflex with visual enhancement. The patient is asked to stare at the fixed fixation dot on the wall. The person assessing the patient slowly moves the patient s head at about 0.5 Hz and with an amplitude of 10 in the horizontal plane or in the vertical plane. The patient should maintain fixation on the dot for the duration of the test. VORS (VOR Suppression) This test type assesses the patient s vestibulo-ocular reflex without visual enhancement. The patient is asked to stare at the laser dot on the wall. This laser dot will move with the head. The person assessing the patient slowly moves the patient s head at about 0.5 Hz with amplitude of 10 in the horizontal plane or in the vertical plane. The patient should continue to follow the laser dot for the duration of the test. This test may be performed in a darkened room Collecting VOR data Note The temporary patient is available to allow testing to start without entering any patient data. Refer to 46 Otometrics - ICS Impulse USB

47 4 Oculomotor Patient data entry 20 to create a new patient or open an existing patient. 1. The Synchronized Room Video will be displayed. Due to the faster frame rate acquisition of the camera, the Head Position Feedback is not viewable for VOR tests. 2. Instruct the patient. (For example, tell them to keep their eyes open and stare at the fixation dot.) 3. To begin data collection, click Start or click the left button on the presentation remote. Trace recordings display in the Real Time Traces window. This display includes the eye and head velocities. Note You can find more information in the ICS Impulse training video or at Otometrics - ICS Impulse USB 47

48 4 Oculomotor Displayed in the Collection window are: Test Type name of test for which data has been collected (The name includes the test direction and the test conditions.) Elapsed Time duration of the test (Also, the test date and time is displayed). Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A. Test Type B. Elapsed Time C. Frame Rate D. Calibration The system automatically stops when the maximum test duration is reached. To stop the test early, click Stop or press the right button on the presentation remote. Data will be saved. To stop the test early, without saving data, click Cancel. (The maximum test duration is set in Test Options.) The data is analyzed and displayed in the Analysis window VOR data analysis To view a specific test, click on the Test window tab and then click the desired test to highlight it. For more information about selecting the test, refer to Selecting a test 16. Analysis of the test results can be viewed in the Analysis window. To enlarge one window within the group, click the small box in the top right corner of that window. To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. For more information about switching between viewing modes (normal mode or enlarged mode), refer to Switching between viewing modes Otometrics - ICS Impulse USB

49 4 Oculomotor Analysis window Real Time Traces Traces in the graph display the eye and head velocity during data collection. You can choose to display or not display a trace by clicking the check box in the trace legend. To view an entire trace use the scroll bar below the trace. The report prints the part of the trace seen in the Traces window centered around the cursor Analysis details Info The test parameters are listed: Test Type name of test for which data has been collected Operator the person who was logged into OTOSuite Vestibular software when the data was collected Calibration the distance in pixels between the right and left eye positions measured during calibration Test Time date and time data collection was started Elapsed Time duration of the test Remarks Remarks regarding the test can be entered before, during, and after testing. To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Note Text previously added in the Test window appears in the Remarks window. Otometrics - ICS Impulse USB 49

50 4 Oculomotor Playback of data collection The eye and head velocity traces and the eye video can be played back synchronously with the room video. Video Playback buttons and selections Play Pause Stop Play from Cursor Speed Plays the video Pauses the video Stops the video Select to start the playback at the position of the cursor. If not selected, playback starts at the beginning of the trace. Note Before setting the playback speed, check the recorded frame rate (fps) stated below the eye video. Normal - eye video recorded at 30 frames per second can only be played back at normal speed. Slow - eye video recorded at 60 frames per second can be played back at normal or slow speed. Slower - eye video recorded at > 60 frames per second can be played back at normal, slow, or slower speed Skew Deviation test In this test, the goggles collect eye data. The high speed camera captures the image of the eye. The OTOsuite Vestibular software processes the eye position data and calculates the degrees of eye deviation. The test provides the ability to assess the patient s ocular alignment using an alternate cover test. The purpose of this test is to identify if ocular misalignment occurs as a result of covering and uncovering the eye. The patient is in a sitting position. The patient s eye movement is recorded with the eyes in the primary position and as the left eye is covered and uncovered Collecting Skew Deviation data Note The temporary patient is available to allow testing to start without entering any patient data. Refer to Patient data entry 20 to create a new patient or open an existing patient. 1. The Synchronized Room Video will be displayed. The Head Position Feedback is not viewable for the Skew Deviation test because the head is stationary. 2. Instruct the patient. (For example, tell them to keep the eyes open and stare straight ahead.) 50 Otometrics - ICS Impulse USB

51 4 Oculomotor 3. To begin data collection, click Start or click the left button on the presentation remote. Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. (The default display is set in Test Options.) 4. During data acquisition, in order for the average eye position shift to be calculated correctly, manually indicate when the eye is covered or uncovered. Click the left button on the presentation remote. This button toggles between covered and uncovered. Or, click Cover/Uncover. With each click, the icon for eye covered,, or the icon for eye uncovered,, is inserted below the trace. Note You can find more information in the ICS Impulse training video or at Otometrics - ICS Impulse USB 51

52 4 Oculomotor Displayed in the Collection window are: Test Type name of test for which data has been collected Elapsed Time duration of the test (Also, the test date and time is displayed). Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A. Test Type B. Elapsed Time C. Frame Rate D. Calibration The system automatically stops when the maximum test duration is reached. To stop the test early, click Stop or press the right button on the presentation remote. Data will be saved. To stop the test early, without saving data, click Cancel. (The maximum test duration is set in Test Options.) The data is analyzed and displayed in the Analysis window Skew Deviation data analysis To view a specific test, click on the Test window tab and then click the desired test to highlight it. For more information about selecting the test, refer to Selecting a test 16. Analysis of the test results can be viewed in the Analysis window. To enlarge one window within the group, click the small box in the top right corner of that window. To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. For more information about switching between viewing modes (normal mode or enlarged mode), refer to Switching between viewing modes Otometrics - ICS Impulse USB

53 4 Oculomotor Analysis window Eye Position Traces Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. You can choose to display or not display a trace by clicking the check box in the trace legend.(the default display is set in Test Options.) The traces are displayed with the culmination phase (area with the most robust response) centered in the middle of the window. To view an entire trace use the scroll bar below the trace. The report prints the part of the trace seen in the Traces window centered around the cursor Analysis details Info The test parameters are listed: Test Type name of test for which data has been collected Operator the person who was logged into OTOSuite Vestibular software when the data was collected Calibration the distance in pixels between the right and left eye positions measured during calibration Test Time date and time data collection was started Elapsed Time duration of the test Avg Eye Position Shift (deg) the average eye position deviation (for the horizontal and vertical traces) when the condition changes between the eye being covered and uncovered Remarks Remarks regarding the test can be entered before, during, and after testing. To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Otometrics - ICS Impulse USB 53

54 4 Oculomotor Note Text previously added in the Test window appears in the Remarks window Playback of data collection The eye position traces and the eye video can be played back synchronously with the room video. Video Playback buttons and selections Play Pause Stop Play from Cursor Speed Plays the video Pauses the video Stops the video Select to start the playback at the position of the cursor. If not selected, playback starts at the beginning of the trace. Note Before setting the playback speed, check the recorded frame rate (fps) stated below the eye video. Normal - eye video recorded at 30 frames per second can only be played back at normal speed. Slow - eye video recorded at 60 frames per second can be played back at normal or slow speed. Slower - eye video recorded at > 60 frames per second can be played back at normal, slow, or slower speed. 54 Otometrics - ICS Impulse USB

55 5 Head Impulse 5 Head Impulse These functions are available in the Head Impulse group: Impulse Test 2D Analysis (refer to Head Impulse single-test data analysis 69) Hex Plot (refer to Hex Plot window 79) 3D Analysis (refer to Head Impulse single-test data analysis 69) Progress Graphs (refer to Head Impulse multiple-tests data analysis 85) Progress Data (refer to Head Impulse multiple-tests data analysis 85) 5.1 Test environment The environment can vary but must allow you to position the patient at least one meter from the wall (or other solid surface that can be used as a projection surface). For Calibration and Test Purposes: Note The patient should be seated in a chair that is stationary and does not swivel. 1. Choose a wall that allows you to position the patient at least one meter in front of the fixation dot. 2. Apply one of the fixation dots supplied with the system to the wall in a location that allows you to position the patient directly in front of the fixation dot. 5.2 Pupil detection Lateral test Refer to Goggles placement 27 for placement instructions. Note It is recommended to do the Lateral test prior to doing either the LARP or RALP test. Calibration must be with Lateral test type selected. 1. Choose the Impulse Type: Lateral. 2. For patients with spontaneous nystagmus or gaze-evoked nystagmus (evoked by gaze position during head impulse), select the check box Spontaneous Nystagmus. By selecting this check box for a patient who has spontaneous nystagmus or gaze-evoked nystagmus, it prevents good impulses from being rejected inappropriately. 3. Position the patient at least one meter in front of the wall. (Refer to Test environment 55 for information.) Otometrics - ICS Impulse USB 55

56 5 Head Impulse Note The Center button is disabled when Lateral is the selected Impulse Type. 4. Position the ROI (Region of Interest) around the pupil: click on the green box and drag to center it on the pupil, or click on the pupil to center the pupil inside the green box. Note For Head Impulse and VOR tests the ROI box is 100 x 100 pixels with a maximum sampling rate of 250 fps. For all other tests the ROI box is 160 x 120 pixels with a maximum sampling rate of 173 fps. 5. In the Video window, choose the type of image displayed: Grayscale Image (A) or Pupil Location (B). Note The choice of Grayscale Image or Pupil Location is only used for setting the pupil detection. Eye video is always recorded in grayscale. 6. If the pupil was not automatically detected, select Auto-Threshold. The system centers the cross-hair on the pupil. 7. Ask the patient to stare at the fixation dot. Assess pupil tracking by observing the cross-hair. If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), use the + or button of the threshold slider to adjust. 56 Otometrics - ICS Impulse USB

57 5 Head Impulse Pupil detection ensures that the system tracks the pupil properly during calibration and when collecting data. Note When Image Display is set to Pupil Location, make additional adjustments to remove any white areas outside the white circular image of the pupil. 8. Select OK to accept the ROI position. 9. Continue to Calibration LARP or RALP test Note It is recommended to do the Lateral test prior to doing either the LARP or RALP test. Calibration must be performed with Lateral test type selected. This procedure assumes that the test is performed after the Lateral test. 1. Choose the Impulse Type: LARP or RALP. Choosing the impulse type determines which plane of the gyroscopes (i.e., head trace) should be bold in the Real Time Trace. It also determines the shape of the training curves. 2. For patients with spontaneous nystagmus or gaze-evoked nystagmus (evoked by gaze position during head impulse), select the check box Spontaneous Nystagmus. By selecting this check box for a patient who has spontaneous nystagmus or gaze-evoked nystagmus, it prevents good impulses from being rejected inappropriately. Note Clicking Center sets the reference point used to provide feedback for head position during testing. The button is disabled if Head Position Feedback is not selected in the Test Options. For information about changing settings, please refer to Options Ensure that the patient's head is not moving and that it is perfectly centered. Click Center or press the left button on the presentation remote. Otometrics - ICS Impulse USB 57

58 5 Head Impulse 4. Move the head to the right (LARP test) or to the left (RALP test) observing the head position feedback graphic. Note The head position feedback is a guide to assist in proper data collection. The tester should always use their clinical judgment when positioning the patient. The position may vary based on the patient's neck mobility. The head position feedback is a guide to assist in proper data collection. The tester should always use their clinical judgment when positioning the patient. The position may vary based on the patient's neck mobility. Green indicates an optimal head rotation. Yellow indicates a head rotation between or Position the ROI (Region of Interest) around the pupil: click on the green box and drag to center it on the pupil, or click on the pupil to center the pupil inside the green box. 6. Ask the patient to stare at the fixation dot. Assess pupil tracking by observing the cross-hair: If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), move the threshold slider to adjust. 7. Select OK to accept the ROI position. Note The calibration values are automatically saved. The stored calibration value can be used for all tests. There is no need to recalibrate between tests unless the goggles have moved. If you exit out of the patient s file and reopen, calibration will need to be performed again. 8. If a Lateral test was performed prior to starting this test, continue to (Optimizing collection 63). 58 Otometrics - ICS Impulse USB

59 5 Head Impulse 5.3 Calibration Caution During this procedure both lasers will turn on. Do not look directly at the lasers. Use of controls or adjustments, or performance of procedures other than those specified herein, may result in hazardous radiation exposure. 1. Click Lasers On to turn on both lasers. 2. Ask the patient to position the left and right dots equidistant on each side of the fixation dot. 3. Ask the patient to look at the left dot, then at the right dot. In the Video window, check that the cross-hair continues to track the pupil. Note Use the Real Time Traces window to monitor incoming data. By observing the head trace (orange/blue/pink) and the eye trace (green), you can tell if the patient is moving their head or eyes (instead of staring at the fixation dot), blinking excessively, or not following instructions being given (not cooperating). 4. If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), use the + or button of the threshold slider to adjust. Otometrics - ICS Impulse USB 59

60 5 Head Impulse In the calibration procedure, the patient is asked to switch their gaze between the two dots that appear when the lasers are on. As the patient s gaze switches, the system tracks the movement of the pupil. Note When a patient cannot be calibrated (for example the vision is so poor that the patient cannot see the fixation dot or laser beams dots), click Default to use the calibration default value ( = 21). The eye movement between the two laser beam dots is measured and calibrated against the known values the laser beam dots projected from the goggles. The calibration values relate to the pixel location that equates to 7.5 degrees left and right of center. The difference between the left and right equates to the number of pixels for a 15 degree movement of the eye. These values are used to analyze eye movement during the impulse testing. Refer to Calibration algorithm 174 for additional information. 5. Click Run. 6. Ask the patient to face the fixation dot and hold their head still. 7. Ask the patient to follow the laser beam dot. Note The calibration values are automatically saved. The stored calibration value can be used for all tests. There is no need to recalibrate between tests unless the goggles have moved. If you exit out of the patient s file and reopen, calibration will need to be performed again. Calibration check 1. Ask the patient to stare at the fixation dot and move the head side to side through a small angle (about 10 degrees). 2. Check that the eye and head velocities match. 60 Otometrics - ICS Impulse USB

61 5 Head Impulse Good calibration - Eye and head velocities match Poor calibration - Eye velocity is too low Poor calibration - Eye velocity is too high 3. If the eye and head velocities do not match, you need to recalibrate or review the patient s history. Otometrics - ICS Impulse USB 61

62 5 Head Impulse Note If the patient has to make catch-up saccades during low frequency head rotations, this can indicate either vestibular loss, or cerebellar dysfunction, or both. When test results include catch-up saccades during low frequency head rotations, it is recommended that the Impulse test results be interpreted with caution. Data NOT within normal limits could be related to a peripheral and/or central disorder. Use the VOR tests to assess a patient with catch-up saccades during calibration check. 4. Once the calibration has been checked and you are satisfied with the result, click Accept. The Collection window opens and the software is ready to begin collecting head impulse data. Caution Once calibration has been performed, it is recommended not to reposition the goggles on the patient s head. 62 Otometrics - ICS Impulse USB

63 5 Head Impulse 5.4 Video recording eye movement during testing The Video window displays the image of the eye. To start the video recording at the same time as data collection starts, select the check box Auto Record (B). To control the recording manually, click Record (A) to start the recording and Stop (C) to stop the recording. Note Refer to Playback 114 for information about playing back a video. 5.5 Optimizing collection It is best to perfect doing the lateral head impulse test before collecting data using LARP/RALP. LARP/RALP impulse tests are more difficult to perform and familiarity with the lateral head impulse test will increase success with data collection for LARP/RALP impulse tests. The basic head impulse test starts with the tester standing behind the patient who is wearing the goggles. While the patient is asked to stare at the fixation dot placed on a surface in front of them, the tester rotates the patient s head horizontally for a lateral head impulse test through a small angle (about degrees) in a brief, abrupt and unpredictable manner, varying the direction and the velocity. For LARP, turn the patient s head degrees to the right. Have the patient stare at the fixation dot. The pupil of the right eye will be close to the nose. The tester places one hand under the patient s chin and one on the top of the patient s head and rotates the patient s head vertically through a small angle in pitch (about degrees) in a brief, abrupt and unpredictable manner, varying the direction and the velocity. A head impulse downward stimulates the left anterior canal. A head impulse upward stimulates the right posterior canal. For RALP, turn the patient s head degrees to the left. Have the patient stare at the fixation dot. The pupil of the right eye will be close to right side of their head. The tester places one hand under the patient s chin and one on the top Otometrics - ICS Impulse USB 63

64 5 Head Impulse of the patient s head and rotates the patient s head vertically through a small angle in pitch (about degrees) in a brief, abrupt and unpredictable manner, varying the direction and the velocity. A head impulse downward stimulates the right anterior canal. A head impulse upward stimulates the left posterior canal. Lateral Head Impulse Stimulus Displacement: Minimum Acceptable Peak Head Velocity: 120 /s 250 /s Peak Head Acceleration: 1200 /s /s 2 LARP Head Impulse Stimulus Displacement: Minimum Acceptable Peak Head Velocity: 100 /s 250 /s Peak Head Acceleration: 1000 /s /s 2 RALP Head Impulse Note You can find more information in the ICS Impulse training video, at icsimpulse.com, or at headimpulse.com. The goggles collect both head and eye data. The gyroscope measures the velocity of the head movement (the stimulus). The high-speed camera captures the image of the eye. The OTOsuite Vestibular software processes the head velocity data and velocity data for eye movement (the response). Simultaneous displays of the data for head movement and for eye movement allow the clinician to determine if the response is within normal limits or not. 64 Otometrics - ICS Impulse USB

65 5 Head Impulse 5.6 Collecting Head Impulse data Note The temporary patient is available to allow testing to start without entering any patient data. Refer to Patient data entry 20 to create a new patient or open an existing patient. 1. The Impulses settings (A) define how many valid left and right impulses are required before the test stops automatically. To change the number of suggested minimum head impulses for the current testing session, click the up or down arrows or type in the number directly. Twenty (20) is the recommended minimum number of head impulses for both leftward and rightward impulses. Note Impulse settings can be any number up to 999. For information about setting the default numbers, refer to Head Impulse 135. Otometrics - ICS Impulse USB 65

66 5 Head Impulse During testing, valid impulses display for both left and right impulses (B). The left and right impulses that are not properly performed are combined into the rejected count (C). A head movement with a peak head velocity below the minimum is not considered an impulse: Lateral test minimum is 120 /s 250 /s LARP and RALP test minimum is 100 /s 250 /s Note Impulses will be rejected if the frame rate drops below 219 frames/second. 2. A disabled (grayed out) Start button indicates the system is ready for head impulse data collection. Otherwise you must click Start or click the left button on the presentation remote to begin head impulse data collection. Caution Touching the goggles or the goggles strap while moving the patient s head can result in moving the camera which produces artifacts in the collection data. 3. Standing behind the patient, place your hands on the patient s head well away from the goggles and the goggles strap. Note You can find more information in the ICS Impulse training video or at 66 Otometrics - ICS Impulse USB

67 5 Head Impulse 4. Ask the patient to stare at the fixation dot and move the patients head as described in Optimizing collection 63. It is important to have reviewed the ICS Impulse Training Video. The system automatically stops when the minimum numbers for left and right impulses have been reached. Displayed in the Collection window are: Impulse Type name of test for which data has been collected Elapsed Time duration of the test (Also, the test date and time is displayed). Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A. Test Type B. Elapsed Time C. Frame Rate D. Calibration Note To stop the test early, click Stop or press the right button on the presentation remote. Data will be saved. (Data is saved if at least one good impulse has been collected.) To stop the test early, without saving data, click Cancel. The data is automatically analyzed and displayed in the 2D Analysis window. Otometrics - ICS Impulse USB 67

68 5 Head Impulse Monitoring eye and head movement While performing the head impulse test, both the Real Time Traces window and the Impulse window display head and eye traces to assist you in understanding the quality of data being collected Real Time Trace window This window allows you to monitor both head and eye movement while performing the head impulse test. The type of impulse selected (Lateral, LARP, or RALP) determines which head trace is bold. The bold head trace should be the one moving when the head impulse is delivered. The other two head traces should be fairly flat. This ensures that the canal stimulated is the one you intended to test. During the test, the maximum sample rate is 250 samples per second. Operator feedback is also displayed for the current impulse: A green circle indicates that the head impulse was accepted (performed adequately). An orange circle indicates that the head impulse was rejected (not performed properly). A message displays in the collection window if one of these errors was the cause: Too slow - head velocity not fast enough Too much overshoot - at the end of the impulse the head was moved in the direction opposite of the test direction, or Wrong planes stimulated - when performing the LARP or RALP test, the impulse was delivered in planes that stimulated semi-circular canals other than those being tested. Note By default, operator feedback displays during collection. If you prefer to not display operator feedback, refer to Head Impulse Otometrics - ICS Impulse USB

69 5 Head Impulse Impulse window In this window, the gray training curves represent the shape of good head impulses at a variety of velocities: 100, 150, 200, and 250. The shape of the training curves changes based on the type of impulse selected (Lateral, LARP, RALP). The head trace displayed in orange and with negative velocities represents movement to the right. The head trace displayed in blue and with positive velocities represents movement to the left. The actual head and eye traces are superimposed on top of the gray training curves. The eye trace is represented in green. White dots display along the Y axis to indicate the velocities of impulses collected. The collection algorithm analyzes the data in real-time as it is being collected. If the head impulse meets the algorithm criteria, an accepted head impulse will be counted in the collection window. A head impulse that matches the training curve is typically counted as an accepted (valid) head impulse. Comparing the actual head traces (in this example shown in blue) against the training curves helps ensure that the tester performs quality head impulses and that only good data is included in the analysis. Note You can find more information in the ICS Impulse training video or at Head Impulse single-test data analysis To view a specific test, click on the Test window tab and then click the desired test to highlight it. For more information about selecting the test, refer to Selecting a test 16. Here you will also find information about reordering the list to make it easier to locate a specific test. Analysis of the test results can be viewed in the 2D, Hex Plot, or 3D Analysis window group. To enlarge one window within the group, click the small box in the top right corner of that window. To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. Otometrics - ICS Impulse USB 69

70 5 Head Impulse For more information about switching between viewing modes (normal mode or enlarged mode), refer to Switching between viewing modes Analysis details Gain Reviewing the eye and head traces is the first step in interpreting the data. (See 2D Analysis window 75.) Reviewing the gain data should always be secondary. Gain is the ratio of the eye movement velocity to the head movement velocity. Individual gains and the mean gain are displayed. The Gain window displays gain values along the Y axis and corresponding peak velocities along the X axis. (The peak velocity is the maximum velocity for each of the 175 samples representing that particular head impulse test.) The gain graph will auto scale above 1.2 if there are individual gains between 1.2 and 3. In the gain graph, the right and left means are indicated by Xs. At the top of the graph a legend identifies the colors used for left and right values. 70 Otometrics - ICS Impulse USB

71 5 Head Impulse Displayed above the graph are the values for the right and left means (A), the right and left standard deviations (B), and the asymmetry (C). The method for calculating relative right-left vestibulo-ocular reflex asymmetry (the Asymmetry value) is as follows. (1) ( lower gain higher gain ) x Asymmetry % = The calculation is specific to the planes tested: Lateral (right lateral to left lateral) or LARP (left anterior to right posterior) or RALP (right anterior to left posterior). Normative data Normative cutoff values are defined according to data research. (2) Shading indicates the boundaries for data outside of the normative cutoff values: Data in the white zone is within normal limits. Data in the light gray area indicates unilateral loss. Data in the dark gray area indicates bilateral loss. To change the normative cutoff values, refer to Head Impulse 135. (1) Newman-Toker DE, Saber-Tehrani AS, Mantokoudis G, Pula JH, Guede CI, Kerber KA, Blitz A, Ying SH, Hsieh YH, Rothman RE, Hanley DF, Zee DS, Kattah JC. Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke.2013;STROKEAHA (2) MacDougall HG, Weber KP, McGarvie LA, Halmagyi GM, Curthoys IS (2009) The video head impulse test: Diagnostic accuracy in peripheral vestibulopathy. Neurology 73 (14): Otometrics - ICS Impulse USB 71

72 5 Head Impulse Age-based normative data Age-based normative cutoff values are defined as the mean ± 2 standard deviations for the age range 10 to 99 years. (1) On the gain graph, an outline defines the area inside of which the data is considered within normal limits. Gain values above 1.2 Gain values above 1.2 could be the result of one of these issues or a combination of them: 1. Slippage of the goggles. Make sure the strap is tight, the cable from the goggles is clipped to the patient s right shoulder or collar with some slack, and there are not gaps between the foam cushion and the patient s face. For pictures showing good and poor goggles placement, refer to Goggles placement 27. The tester should not touch the strap or goggles during the head impulse test. 2. Patient is too close to the fixation dot. If the patient is closer than 1 meter, you will see increased VOR gains due to convergence of the eyes. Never stand in front of the patient and have them fixate on your nose when using ICS Impulse. This method of testing will result in higher VOR gains. 3. During testing, the real time trace showed that the eyes were leading the head but the test was allowed to continue. If this problem is observed, the goggles and patient setup should be checked before continuing the test. 4. If you have ruled out 1, 2, and 3 it could be that the patient has Meniere s Disease. (2) Displaying data and values To view only left or right gains, click the Display window tab and click the Left or Right check box. To view both left and right gains, select both check boxes. (1) McGarvie L, Halmagyi M, Curthoys I, MacDougall H. Video head impulse testing age dependent normative values in healthy subjects. XXVIII Meeting of the Bárány Society, Buenos Aires, Argentina, May, Journal of Vestibular Research 24 (2-3), 77. Curthoys IS, McGarvie L, MacDougall H, Burgess A, Chiarovano E, de Waele C, Halmagyi M. The video head impulse test (vhit) of semicircular canal function; 1. Sensitivity and specificity for vestibular loss and 2. Age dependent norms in healthy subjects. Oral presentation S501 at the Neuro-Otology Society of Australia's 24th Annual Clinical and Scientific Meeting, 8-10 August, 2014, Royal Prince Alfred Hospital, Sydney, Australia. McGarvie L, MacDougall H, Chiarovano E, de Waele C, Curthoys I. The video head impulse test (vhit) of semicircular canal function: True sensitivity, specificity and age dependent norms in healthy subjects. Poster no. 2, presented at Frontiers 2014: The Art, Science and Future of Otorhinolaryngology, 30 July-1 August 2014, Sheraton on the Park, Sydney, Australia. Ian Curthoys, Leigh McGarvie, Hamish MacDougall, Ann M Burgess, Samanthi Goonetilleke, Michael Halmagyi, Elodie Chiarovano, Catherine de Waele Metrics of the Video Head Impulse Test (vhit) of Semicircular Canal Function; Sensitivity and Specificity for Detecting Known Vestibular Loss and Age Dependent Norms for vhit in Healthy Subjects. Accepted for 2015 Midwinter meeting of the Association for Research in Otolaryngology, Baltimore. Feb 22,2015 (2) Manzari et al. Rapid fluctuations in dynamic semicircular canal function in early Meniere s disease. Eur Arch Otorhinolaryngol 14 Dec Otometrics - ICS Impulse USB

73 5 Head Impulse Gain, peak velocity, and saccade latency values for an individual impulse display in the status bar (A) whenever a gain point or a trace is selected. Select a gain point: Click in the Gain window (B) and move the cursor over the gain point to select it. The gain value(c) for the selected point displays next to the point. In the trace window, the corresponding trace is highlighted. Select a trace: Click in the trace window (D) and use the arrow keys or the scroll wheel on the mouse to move from trace to trace. The highlighted trace is the selected trace(e). In The corresponding gain point is selected (gain value is not displayed). A. Status bar B. Gain window C. Gain value D. Trace window E. Selected trace To delete a selected head impulse: Move the cursor over the gain point. Double-click the mouse. Click in the trace window. Use the arrow keys or the scroll wheel on the mouse to select an individual trace. Press the Delete key. To restore all deleted head impulses, click the Reanalysis window tab. Click Restore Deleted Data. Otometrics - ICS Impulse USB 73

74 5 Head Impulse About saccades For a peak to be considered a saccade it must meet these criteria: Identified as a saccade by our proprietary algorithm (by default peaks identified as saccades are red) Occurring 70 ms or later after the head movement (the impulse) began Info Impulse Analysis data is reported for both leftward and rightward head impulses as well as rejected head impulses. OTOsuite Vestibular uses different algorithms to analyze impulses. Collection impulses (the head impulse data that passed the collection algorithm as shown in the collection window) Analysis impulses (the head impulse data that passed the analysis algorithm) The number of collection and analysis impulses may vary slightly. For more information, refer to Head Impulse Collection and Analysis algorithms 175. Avg. Number of Saccades data is reported for both leftward and rightward head impulses. Overt total number of saccades that occur after the head velocity crosses the zero point Covert total number of saccades that occur after 70 msec and before the head velocity crosses the zero point Total total number of overt and covert saccades The operator name and test parameters are listed: Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A note displays whenever the catch-up saccade parameters have been modified Remarks Remarks regarding the test can be entered before, during, and after testing. To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Note Text previously added in the Test window appears in the Remarks window. 74 Otometrics - ICS Impulse USB

75 5 Head Impulse Display To change the Gain graph display, click the Left and/or Right check boxes to select/deselect what displays: both gains, left gains only, or right gains only. To modify the 2D graphs display, click the Head Velocity and/or Eye Velocity check boxes to select/deselect what displays: both velocities, head velocity only, or eye velocity only Reanalysis Restore Deleted Data - restores all original gain data points. Spontaneous Nystagmus - The check box Spontaneous Nystagmus is checked if the tester selected the Spontaneous Nystagmus check box in the Collection window. Catch-up Saccade Parameters Left/Right - choose to modify the catch-up saccade parameters for the left or right head impulse Restore Defaults - restore the catch-up saccade parameters to the manufacturer defaults for the selected side (left/right) Baseline Amplitude - This setting identifies a saccade based on how steep the slope is on the backside of a saccade. Adjust this slider if you believe an eye movement is misidentified as a saccade or that the eye movement should be identified as a saccade. Start Position - This setting determines where the software starts to look for the presence of a saccade. Adjust this slider if you believe an eye movement is misidentified as a saccade or that the eye movement should be identified as a saccade D Analysis window Default colors for data shown in the graphs allow those who are color blind to easily distinguish the different colors. To change the colors used for each type of data, click the Graph Colors window tab in the Options window. Refer to Graph Colors 132. Otometrics - ICS Impulse USB 75

76 5 Head Impulse The default layout places the right graph (right head and eye velocity data) on the right and the left graph (left head and eye velocity data) on the left. To switch the layout, click the Head Impulse window tab in the Options window and select Display Left Graph on Right Side. Refer to Head Impulse options 1. To view only the head or eye velocity, click the Display window tab and click the Head Velocity or Eye Velocity check box. To view both head and eye velocities, select both check boxes. Head data is shown in blue for left and orange for right. Eye data shown in green identifies eye movement during and after the head impulse (VOR). Eye data shown in red identifies saccadic eye movement (in other words, the catch-up saccades). Data is shown with velocity plotted on the Y axis and impulse milliseconds or samples along the X axis. For data that was converted from an earlier version of software, the X axis will display in samples if the average frame rate was below Otometrics - ICS Impulse USB

77 5 Head Impulse Understanding the 2D analysis Within Normal Limits In this example of head impulse data, both sides are within normal limits. Looking at the Gain graph the data points are all within the normal range (in the white area). The head data shows very well performed head impulses and the eye data shows a vestibular ocular reflex (A) that mirrors the head velocities. There may be a few catch-up saccades. Otometrics - ICS Impulse USB 77

78 5 Head Impulse Overt saccades This is an example of head impulse data that exhibits an abnormal vestibular ocular reflex on the left side indicated by the gain response and the catch-up saccades. Looking at the Gain graph the data points are all within the gray range indicating a unilateral loss. The head data shows very well performed head impulses and the eye data shows an inadequate vestibular ocular reflex (A) that does not mirror the head velocities. There are overt catch-up saccades present (B). Catch-up saccades are easier to visualize in the 3D analysis. 78 Otometrics - ICS Impulse USB

79 5 Head Impulse Covert Saccades This is an example of head impulse data that exhibits an abnormal vestibular ocular reflex on the right side indicated by the gain response and the catch-up saccades. Looking at the Gain graph the data points are all within the gray range indicating unilateral loss. Note the asymmetry of 56%. The right (abnormal) side is affecting the left (normal) side. The head data shows well performed head impulses and the eye data shows an inadequate vestibular ocular reflex (A) that does not mirror the head velocities. There are covert catch-up saccades present (B). Catch-up saccades are easier to visualize in the 3D analysis Hex Plot window The Hex Plot window provides an overview of the mean gains as well as the 2D analysis graphs for all selected tests. The tests initially selected are the same as the tests selected in the 2D and 3D Analysis windows. Mean gains are represented by bars that vary in length according to the mean gain value. The bars are displayed inside a hexagon. Each side of the hexagon is labeled with a two-letter abbreviation that refers to one of the six semicircular canals: LA (left anterior) RA (right anterior) LL (left lateral) RL (right lateral) LP (left posterior) RP (right posterior) The outer hexagon represents a mean gain of 1.0. The inner hexagon represents a mean gain of 0.5. The gain bars are colored according to normative cutoff settings made in the Head Impulse Options window. Refer to Head Impulse 135. Default colors for data shown in the graphs allow those who are color blind to easily distinguish the different colors. To change the colors used for each type of data, click the Graph Colors window tab in the Options window. Refer to Graph Colors 132. Otometrics - ICS Impulse USB 79

80 5 Head Impulse The default layout places the right graph (right head and eye velocity data) on the right and the left graph (left head and eye velocity data) on the left. To switch the layout, click the Head Impulse window tab in the Options window and select Display Left Graph on Right Side. Refer to Head Impulse options 1. To remove a test(s), click the button next to the test name in the Show column. To add a test(s), click the button next to the test name in the Show column. Only one test for each test type may be selected to display on the hex plot. Note The test selections revert back to the test selections in the 2D and 3D Analysis windows when the Hex Plot window is no longer displayed. (A) The method for calculating relative right-left vestibulo-ocular reflex asymmetry (the Asymmetry values) is as follows. (1) lower gain ( ) x Asymmetry % = higher gain The calculation is specific to each set of canals: anterior to anterior, lateral to lateral, and posterior to posterior. (1) Newman-Toker DE, Saber-Tehrani AS, Mantokoudis G, Pula JH, Guede CI, Kerber KA, Blitz A, Ying SH, Hsieh YH, Rothman RE, Hanley DF, Zee DS, Kattah JC. Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke.2013;STROKEAHA Otometrics - ICS Impulse USB

81 5 Head Impulse D Analysis window Default colors for data shown in the graphs allow those who are color blind to easily distinguish the different colors. To change the colors used for each type of data, click the Graph Colors window tab in the Options window. Refer to Graph Colors 132. The default layout places the right graph (right head and eye velocity data) on the right and the left graph (left head and eye velocity data) on the left. To switch the layout, click the Head Impulse window tab in the Options window and select Display Left Graph on Right Side. Refer to Head Impulse options 1. The data can be viewed from 360 degrees. To see the data from different views, hold down left-mouse button and rotate as desired. To return the data to the original view, click Reset (A). Otometrics - ICS Impulse USB 81

82 5 Head Impulse Understanding the 3D analysis Normal In this example of head impulse data, both sides are within normal limits. Looking at the Gain graph the data points are all within the normal range (in the white area). The head data shows very well performed head impulses and the eye data shows a vestibular ocular reflex (A) that mirrors the head velocities. There may be a few catch-up saccades. 82 Otometrics - ICS Impulse USB

83 5 Head Impulse Overt saccades This is an example of head impulse data that exhibits an abnormal vestibular ocular reflex on the left side indicated by the gain response and the catch-up saccades. Looking at the Gain graph the data points are all within the gray range indicating a unilateral loss. The head data shows very well performed head impulses and the eye data shows an inadequate vestibular ocular reflex (A) that does not mirror the head velocities. There are overt catch-up saccades present (B). On the right side, the downward spikes are due to spontaneous nystagmus. Otometrics - ICS Impulse USB 83

84 5 Head Impulse Covert saccades This is an example of head impulse data that exhibits an abnormal vestibular ocular reflex on the right side indicated by the gain response and the catch-up saccades. Looking at the Gain graph the data points are all within the gray range indicating unilateral loss. Note the asymmetry of 56%. The right (abnormal) side is affecting the left (normal) side. The head data shows well performed head impulses and the eye data shows an inadequate vestibular ocular reflex (A) that does not mirror the head velocities. There are covert catch-up saccades present (B). Notice how the covert catch-up saccades are closer to the head data whereas the overt catch-up saccades were further to the right of the head data. 84 Otometrics - ICS Impulse USB

85 5 Head Impulse 5.8 Head Impulse multiple-tests data analysis Analysis of multiple test sessions can be viewed in the Progress Graphs or Progress Data window group. This allows the user to compare a patient's results from different test dates. By comparing test sessions, the user can see if there is improvement or compensation has occurred. If there are three or more tests available, the three that display initially are the first test, the most recent test, and the test currently displayed in 2D and 3D window. To remove a test from the display, click the button next to the test name in the Show column. To add a test(s) to the display, click the button next to each test name in the Show column. Note The viewing mode functions the same as the 2D and 3D Analysis. Refer to Switching between viewing modes 14. Otometrics - ICS Impulse USB 85

86 5 Head Impulse Progress Graphs Four test sessions can be viewed together in this window. The 3D graphs display as described in 3D Analysis window 81 except that this window displays multiple tests. If more than 4 tests are chosen, a scroll bar will appear on the right to move the window up and down. Default colors for data shown in the graphs allow those who are color blind to easily distinguish the different colors. To change the colors used for each type of data, click the Graph Colors window tab in the Options window. Refer to Graph Colors 132. The default layout places the right graph (right head and eye velocity data) on the right and the left graph (left head and eye velocity data) on the left. To switch the layout, click the Head Impulse window tab in the Options window and select Display Left Graph on Right Side. Refer to Head Impulse options Otometrics - ICS Impulse USB

87 5 Head Impulse Progress Data The gain graph displays as described in Analysis details 70 except that the legend to identify the colors used for each test is shown in the test selection window. Otometrics - ICS Impulse USB 87

88 6 Positional 6 Positional Note The Oculomotor and Positional modules are pending FDA clearance and are not available in the United States. 6.1 Test environment The environment can vary but must allow you to position the patient at least one meter from the wall (or other solid surface that can be used as a projection surface).this position will be utilized for calibration. For Dynamic and Repositioning testing the patient needs to be comfortably positioned on an exam table as they will be moving between a sitting and a supine position. For Calibration Purposes: Note The patient should be seated in a chair that is stationary and does not swivel. 1. Choose a wall that allows you to position the patient at least one meter in front of the fixation dot. 2. Apply one of the fixation dots supplied with the system to the wall in a location that allows you to position the patient directly in front of the fixation dot. 6.2 Video recording eye movement during testing The Video window displays the image of the eye. The Auto-Record (A) is checked by default. The video recording of the eye and data collection start at the same time. 88 Otometrics - ICS Impulse USB

89 6 Positional 6.3 Pupil Detection If using goggles only, refer to Goggles placement 27 for placement instructions. If using the vision-denied solution, refer to Vision-denied solution and goggles placement 29 for placement instructions. 1. Select the test: Dynamic or Repositioning. 2. Select the test type. For example, there are three test types for the Dynamic test: Dix-Hallpike, Hallpike-Stenger, and Roll. 3. Select the test condition. For example, there are four conditions for the Dix-Hallpike test: Head Left, Head Right, Head Left Repeat and Head Right Repeat. 4. If using the vision-denied solution, select the check box Vision Denied. 5. Position the patient at least one meter in front of the wall. (Refer to Test environment 55 for information.) 6. Position the ROI (Region of Interest) around the pupil: click on the green box and drag to center it on the pupil, or click on the pupil to center the pupil inside the green box. Note For Head Impulse and VOR tests the ROI box is 100 x 100 pixels with a maximum sampling rate of 250 fps. For all other tests the ROI box is 160 x 120 pixels with a maximum sampling rate of 173 fps. Otometrics - ICS Impulse USB 89

90 6 Positional 7. In the Video window, choose the type of image displayed: Grayscale Image (A) or Pupil Location (B). Note The choice of Grayscale Image or Pupil Location is only used for setting the pupil detection. Eye video is always recorded in grayscale. 8. If the pupil was not automatically detected, select Auto-Threshold. The system centers the cross-hair on the pupil. 9. Ask the patient to stare at the fixation dot. Assess pupil tracking by observing the cross-hair. If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), use the + or button of the threshold slider to adjust. Pupil detection ensures that the system tracks the pupil properly during calibration and when collecting data. Note When Image Display is set to Pupil Location, make additional adjustments to remove any white areas outside the white circular image of the pupil. 10. Select OK to accept the ROI position. 11. Continue to Calibration Calibration Caution During this procedure both lasers will turn on. Do not look directly at the lasers. Use of controls or adjustments, or performance of procedures other than those specified herein, may result in hazardous radiation exposure. 90 Otometrics - ICS Impulse USB

91 6 Positional 1. Click Lasers On to turn on both lasers. 2. Ask the patient to position the left and right dots equidistant on each side of the fixation dot. 3. Ask the patient to look at the left dot, then at the right dot. In the Video window, check that the cross-hair continues to track the pupil. Note Use the Real Time Traces window to monitor head and eye data. By observing the orange head trace and the green eye trace, you can tell if the patient is moving their head or eyes (instead of staring at the fixation dot), blinking excessively, or not following instructions being given (not cooperating). 4. If the cross-hair fails to track the pupil (jumps around and does not stay centered on the pupil), use the + or button of the threshold slider to adjust. In the calibration procedure, the patient is asked to switch their gaze between the two dots that appear when the lasers are on. As the patient s gaze switches, the system tracks the movement of the pupil. Note When a patient cannot be calibrated (for example the vision is so poor that the patient cannot see the fixation dot or laser beams dots), click Default to use the calibration default value ( = 21). The eye movement between the two laser beam dots is measured and calibrated against the known values the laser beam dots projected from the goggles. The calibration values relate to the pixel location that equates to 7.5 degrees Otometrics - ICS Impulse USB 91

92 6 Positional left and right of center. The difference between the left and right equates to the number of pixels for a 15 degree movement of the eye. These values are used to analyze eye movement during the impulse testing. Refer to Calibration algorithm 174 for additional information. 5. Click Run. 6. Ask the patient to face the fixation dot and hold their head still. 7. Ask the patient to follow the laser beam dot. Note The calibration values are automatically saved. The stored calibration value can be used for all tests. There is no need to recalibrate between tests unless the goggles have moved. If you exit out of the patient s file and reopen, calibration will need to be performed again. Calibration check 1. Ask the patient to stare at the fixation dot and move the head side to side through a small angle (about 10 degrees). 2. Check that the eye and head velocities match. Good calibration - Eye and head velocities match 92 Otometrics - ICS Impulse USB

93 6 Positional (Examples of poor calibration show a calibration performed in Head Impulse) Poor calibration - Eye velocity is too low Poor calibration - Eye velocity is too high 3. If the eye and head velocities do not match, you need to recalibrate or review the patient s history. Otometrics - ICS Impulse USB 93

94 6 Positional Note If the patient has to make catch-up saccades during low frequency head rotations, this can indicate either vestibular loss, or cerebellar dysfunction, or both. When test results include catch-up saccades during low frequency head rotations, it is recommended that the Impulse test results be interpreted with caution. Data NOT within normal limits could be related to a peripheral and/or central disorder. Use the VOR tests to assess a patient with catch-up saccades during calibration check. 4. Once the calibration has been checked and you are satisfied with the result, click Accept. The Collection window opens and the software is ready to begin collecting head impulse data. Caution Once calibration has been performed, it is recommended not to reposition the goggles on the patient s head. 6.5 Optimizing collection and treatment This application provides these features to ensure good data collection and well-performed treatment maneuvers: External Monitor You have the option to display a larger image of the eye on an external monitor. If an external monitor is connected to the computer, position the monitor where you can easily see the eye video. To display the eye video on the computer monitor as well as on an external monitor, click. The external monitor displays the real time SPV value for SPV tests. Note The external monitor is not supported for head impulse testing. 94 Otometrics - ICS Impulse USB

95 6 Positional Head Position Feedback For SPV tests, the Head Position Feedback option is the default setting. When set to this option, a reference graphic of the patient's head position in real time displays on the computer monitor. (Refer to Positional 137 to set the Head Position Feedback option.) Clinically, for dynamic positional testing and for repositioning treatment, positioning the head properly is essential to acquiring the proper diagnosis and successful treatment. Data from the head sensor in the goggles tracks head movement. The head movement seen in the software corresponds directly to the patient's head movement. This assists the tester to position the head in the various positions unique for each dynamic positional test or repositioning maneuver. The semicircular canal(s) being tested or treated is highlighted in green. As the test or maneuver is performed, the blue dot moves with the head. According to the test or treatment maneuver being performed, each position is numbered and represented by a blue line. Move the patient's head aligning the blue dot with each successive numbered blue line. Dix-Hallpike Head Left Canalith Repositioning Treatment (CRT) - rightward 6.6 Dynamic tests In these tests, the goggles collect eye data. The high speed camera captures the image of the eye.the OTOsuite Vestibular software processes the eye position data and calculates the slow-phase velocity (SPV). The Dynamic tests provide the ability to assess nystagmus that occurs from dynamic changes in the patient s body orientation with respect to gravity. The patient typically begins in a sitting position and is moved into a position which will align either the anterior/posterior or the lateral canals perpendicular to the floor and the canal(s) thus affected by gravity. These tests are used to determine if a patient s symptoms are caused by benign paroxysmal positional vertigo. Dix-Hallpike or Hallpike-Stenger This test assesses the anterior and posterior semicircular canals by recording the patient s eye movement during the maneuver. The ANSI standard recommends that this test be performed with vision denied. The patient is sitting. For both tests, the head is turned 45 to the left or right depending on which side is being assessed. Hallpike-Stenger For this test an additional position is included with the head centered and facing straight. The patient is quickly laid back with the head slightly hanging off the end of the exam table. The patient s head is comfortably supported by the examiner during the test. According to the ANSI standard, the eyes should be recorded for a minimum of 20 seconds in this position. It is best to continue recording the eye movement until the nystagmus subsides. The patient is brought back up to the sitting position and eye movement should again be recorded until nystagmus subsides. Otometrics - ICS Impulse USB 95

96 6 Positional Side-Lying The patient is sitting. The head is turned 45 to the opposite side of the affected ear. The patient is laid on the side with the affected ear and the nose turned 30 in the opposite direction. Roll This test assesses the lateral semicircular canals by recording the patient s eye movement during the maneuver. The patient is lying supine with the head tilted up 30 turned so that the affected ear is toward the floor. The head is quickly turned 55 or as far as it will turn to the left or right depending on which side is being assessed. The patient s head is comfortably supported by the examiner during the test. The eyes should be recorded for a minimum of 20 seconds in this position. It is best to continue recording the eye movement until the nystagmus subsides. The patient is brought back up to the sitting position and eye movement should again be recorded until nystagmus subsides. 6.7 Collecting Dynamic data Note The temporary patient is available to allow testing to start without entering any patient data. Refer to Patient data entry 20 to create a new patient or open an existing patient. When collecting data, you can monitor head movement using the Head Position Feedback display (ensures that the head is properly positioned during the entire test or maneuver) or Synchronized Room Video. You can also choose to not use either. (The default display is set in Test Options.) 1. This step applies only when monitoring the head movement during collection: Note Clicking Center sets the reference point used to provide feedback for head position during testing. The button is disabled if Head Position Feedback is not selected in the Test Options. For information about changing settings, please refer to Options 128. If using Head Position Feedback, position the patient's head before starting to collect data. Ensure that the patient's head is not moving and that it is perfectly centered. Click Center or press the left button on the presentation remote. If using Synchronized Room Video, you may need to adjust the camera position to ensure the entire head of the patient is seen in the video during data collection. 2. Instruct the patient. (For example, tell them to keep their eyes open.) 96 Otometrics - ICS Impulse USB

97 6 Positional 3. To begin data collection, click Start or click the left button on the presentation remote. Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. (The default display is set in Test Options.) The real time SPV (slow-phase velocity) value is an estimated value calculated according to the amount of variability around the SPV estimate. The value is displayed in either green or orange in the upper right area of the window. Green: When the variability is low, there is a high probability that the value is reliable. Orange: When the variability is high, there is less probability that the value is reliable. Note SPV values displayed in orange should be considered less reliable but not inaccurate. The real time SPV allows the tester to easily monitor the presence or absence of nystagmus. The tester will know when the nystagmus has subsided and the patient can be moved into the next position. Note You can find more information in the ICS Impulse training video or at Otometrics - ICS Impulse USB 97

98 6 Positional Displayed in the Collection window are: Test Type name of test for which data has been collected (The name includes the test direction and the test conditions.) Elapsed Time duration of the test (Also, the test date and time is displayed). Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A. Test Type B. Elapsed Time C. Frame Rate D. Calibration The system automatically stops when the maximum test duration is reached. To stop the test early, click Stop or press the right button on the presentation remote. Data will be saved. To stop the test early, without saving data, click Cancel. (The maximum test duration is set in Test Options.) The data is analyzed and displayed in the Analysis window. 6.8 Dynamic data analysis To view a specific test, click on the Test window tab and then click the desired test to highlight it. For more information about selecting the test, refer to Selecting a test 16. Analysis of the test results can be viewed in the Analysis window. To enlarge one window within the group, click the small box in the top right corner of that window. To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. For more information about switching between viewing modes (normal mode or enlarged mode), refer to Switching between viewing modes Analysis window Eye Position Traces Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. You can choose to display or not display a trace by clicking the check box in the trace legend.(the default display is set in Test Options.) 98 Otometrics - ICS Impulse USB

99 6 Positional The traces are displayed with the culmination phase (area with the most robust response) centered in the middle of the window. To view an entire trace use the scroll bar below the trace. The report prints the part of the trace seen in the Traces window centered around the cursor. Slow Phase Velocity graph The purpose of this graph is to provide a record of the strength of the nystagmus. This graph displays the individual nystagmus beats identified by the SPV algorithm for the horizontal right (HR) and vertical right (VR) traces. The SPV peak is indicated in the graph by a square. To select a particular beat click on it or use the left/right arrow keys to move between beats. The SPV value for the beat is displayed whenever the mouse is positioned over the beat (A) and in the Info window (B). To choose when analysis begins, refer to Reanalysis 45. Refer to SPV Algorithm 184 for information about how the SPV peak is determined. If the algorithm did not pick a peak, manually set the peak for that trace. Refer to Reanalysis 101. Otometrics - ICS Impulse USB 99

100 6 Positional Analysis details Info The test parameters are listed: Test Type name of test for which data has been collected Operator the person who was logged into OTOSuite Vestibular software when the data was collected Calibration the distance in pixels between the right and left eye positions measured during calibration Test Time date and time data collection was started Elapsed Time duration of the test Begin Time time at which analysis began Beat SPV the slow phase velocity for the selected beat Peak SPV where the slow phase velocity peak is set (For more information, refer to SPV Algorithm 184.) Remarks Remarks regarding the test can be entered before, during, and after testing. To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Note Text previously added in the Test window appears in the Remarks window. 100 Otometrics - ICS Impulse USB

101 6 Positional Reanalysis Analysis Begin Time - All Traces To exclude data in a trace from the analysis: 1. Move the black cursor to the new begin time in the Eye Position Traces window. 2. In the Analysis Details window, click the Reanalysis window tab. 3. To reanalyze, click Reanalyze from Cursor - analyzes all traces with the begin time set to the next full second following the cursor position Reanalyze Full Trace - analyzes all traces from the beginning Note The begin time is displayed in the Info window. SPV Graph Select the trace to modify by choosing HR or VR Delete Beat - excludes the beat from the analysis and on the report Restore Beats - restores all beats that were manually deleted Select Peak click a beat and then select peak. A new peak will be set. See SPV Algorithm 184 for more details on peak determination. Restore Peak restores the peak to the location determined by the algorithm Playback of Data Collection The eye position traces and the eye video can be played back synchronously with the head position feedback or the room video recorded during testing. Video Playback buttons and selections Play Plays the video Otometrics - ICS Impulse USB 101

102 6 Positional Video Playback buttons and selections Pause Stop Play from Cursor Speed Pauses the video Stops the video Select to start the playback at the position of the cursor. If not selected, playback starts at the beginning of the trace. Note Before setting the playback speed, check the recorded frame rate (fps) stated below the eye video. Normal - eye video recorded at 30 frames per second can only be played back at normal speed. Slow - eye video recorded at 60 frames per second can be played back at normal or slow speed. Slower - eye video recorded at > 60 frames per second can be played back at normal, slow, or slower speed. 6.9 Repositioning tests For the Repositioning maneuvers, the goggles collect eye data. The high speed camera captures the image of the eye. The OTOsuite Vestibular software processes the eye position data and calculates the slow-phase velocity (SPV). Repositioning maneuvers are used to treat a patient diagnosed with benign paroxysmal positional vertigo. The maneuvers dynamically change the patient s body orientation with respect to gravity. CRT and liberatory maneuvers begin with the patient in the sitting position. The BBQ roll maneuver begins with the patient in the supine position with the head elevated 30. Then the patient is rotated so that the particles are moved out of the affected canal. Note The Head Position Feedback ensures that the head is properly positioned during each step of the treatment maneuvers. For all Repositioning treatments The treatment can be performed with vision or vision denied. The eyes are recorded in each position until the nystagmus subsides. The patient s head is comfortably supported by the examiner during the test. Anterior and posterior semicircular canals treatments CRT (Canalith repositioning treatment) Liberatory 102 Otometrics - ICS Impulse USB

103 6 Positional CRT (Canalith repositioning treatment) The patient is sitting. The head is turned 45 to the left or right depending on which side is being treated. The patient is laid back with the head slightly hanging off the end of the exam table. Turn the head 90 in the opposite direction. Continue in the same direction and turn the head an additional 90. Liberatory The patient is laid on the affected ear and the nose turned upward 45 in the opposite direction. Move the patient over on the opposite side while maintaining the neck orientation so that the patient is laid on the unaffected ear with the nose turned down 45. Lateral semicircular canals treatment - BBQ Roll The patient is lying supine with the head tilted up 30 turned so that the affected ear is toward the floor. The head is turned 90 or as far as it will turn in the opposite direction of the side being treated. Continue in the same direction with the patient lying on their side and the head maintained at 90 or as far as it will turn. Turn the patient on their stomach with the head tilted 30 facing toward the floor. The patient will continue rotating around in the same direction lying on their side and the head maintained at 90 or as far as it will turn and lastly returning to the starting position Collecting Repositioning data Note The temporary patient is available to allow testing to start without entering any patient data. Refer to Patient data entry 20 to create a new patient or open an existing patient. When collecting data, you can monitor head movement using the Head Position Feedback display (ensures that the head is properly positioned during the entire test or maneuver) or Synchronized Room Video. You can also choose to not use either. (The default display is set in Test Options.) 1. This step applies only when monitoring the head movement during collection: Note Clicking Center sets the reference point used to provide feedback for head position during testing. The button is disabled if Head Position Feedback is not selected in the Test Options. For information about changing settings, please refer to Options 128. If using Head Position Feedback, position the patient's head before starting to collect data. Ensure that the patient's head is not moving and that it is perfectly centered. Click Center or press the left button on the presentation remote. If using Synchronized Room Video, you may need to adjust the camera position to ensure the entire head of the patient is seen in the video during data collection. 2. Instruct the patient. (For example, tell them to keep their eyes open.) Otometrics - ICS Impulse USB 103

104 6 Positional 3. To begin data collection, click Start or click the left button on the presentation remote. Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. (The default display is set in Test Options.) The real time SPV (slow-phase velocity) value is an estimated value calculated according to the amount of variability around the SPV estimate. The value is displayed in either green or orange in the upper right area of the window. Green: When the variability is low, there is a high probability that the value is reliable. Orange: When the variability is high, there is less probability that the value is reliable. Note SPV values displayed in orange should be considered less reliable but not inaccurate. The real time SPV allows the tester to easily monitor the presence or absence of nystagmus. The tester will know when the nystagmus has subsided and the patient can be moved into the next position. Note You can find more information in the ICS Impulse training video or at Otometrics - ICS Impulse USB

105 6 Positional Displayed in the Collection window are: Test Type name of test for which data has been collected (The name includes the test direction and the test conditions.) Elapsed Time duration of the test (Also, the test date and time is displayed). Frame Rate frequency of data acquisition in frames per second (fps) Calibration the distance in pixels between the right and left eye positions measured during calibration A. Test Type B. Elapsed Time C. Frame Rate D. Calibration The system automatically stops when the maximum test duration is reached. To stop the test early, click Stop or press the right button on the presentation remote. Data will be saved. To stop the test early, without saving data, click Cancel. (The maximum test duration is set in Test Options.) The data is analyzed and displayed in the Analysis window Repositioning data analysis To view a specific test, click on the Test window tab and then click the desired test to highlight it. For more information about selecting the test, refer to Selecting a test 16. Analysis of the test results can be viewed in the Analysis window. To enlarge one window within the group, click the small box in the top right corner of that window. To return to the normal viewing mode, click the two overlapping boxes in the enlarged window. For more information about switching between viewing modes (normal mode or enlarged mode), refer to Switching between viewing modes Analysis window Eye Position Traces Horizontal (HR) and vertical (VR) eye position traces display in the Eye Position Traces window. You can choose to display or not display a trace by clicking the check box in the trace legend.(the default display is set in Test Options.) Otometrics - ICS Impulse USB 105

106 6 Positional The traces are displayed with the culmination phase (area with the most robust response) centered in the middle of the window. To view an entire trace use the scroll bar below the trace. The report prints the part of the trace seen in the Traces window centered around the cursor. To choose when analysis begins, refer to Reanalysis 45. Slow Phase Velocity graph The purpose of this graph is to provide a record of the strength of the nystagmus. This graph displays the individual nystagmus beats identified by the SPV algorithm for the horizontal right (HR) and vertical right (VR) traces. The SPV peak is indicated in the graph by a square. To select a particular beat click on it or use the left/right arrow keys to move between beats. The SPV value for the beat is displayed whenever the mouse is positioned over the beat (A) and in the Info window (B). Refer to SPV Algorithm 184 for information about how the SPV peak is determined. If the algorithm did not pick a peak, manually set the peak for that trace. Refer to Reanalysis Otometrics - ICS Impulse USB

107 6 Positional Analysis details Info The test parameters are listed: Test Type name of test for which data has been collected Operator the person who was logged into OTOSuite Vestibular software when the data was collected Calibration the distance in pixels between the right and left eye positions measured during calibration Test Time date and time data collection was started Elapsed Time duration of the test Begin Time time at which analysis began Beat SPV the slow phase velocity for the selected beat Peak SPV where the slow phase velocity peak is set (For more information, refer to SPV Algorithm 184.) Remarks Remarks regarding the test can be entered before, during, and after testing. To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Note Text previously added in the Test window appears in the Remarks window. Otometrics - ICS Impulse USB 107

108 6 Positional Reanalysis Analysis Begin Time - All Traces To exclude data in a trace from the analysis: 1. Move the black cursor to the new begin time in the Eye Position Traces window. 2. In the Analysis Details window, click the Reanalysis window tab. 3. To reanalyze, click Reanalyze from Cursor - analyzes all traces with the begin time set to the next full second following the cursor position Reanalyze Full Trace - analyzes all traces from the beginning Note The begin time is displayed in the Info window. SPV Graph Select the trace to modify by choosing HR or VR Delete Beat - excludes the beat from the analysis and on the report Restore Beats - restores all beats that were manually deleted Select Peak click a beat and then select peak. A new peak will be set. See SPV Algorithm 184 for more details on peak determination. Restore Peak restores the peak to the location determined by the algorithm Playback of Data Collection The eye position traces and the eye video can be played back synchronously with the head position feedback or the room video recorded during testing. Video Playback buttons and selections Play Plays the video 108 Otometrics - ICS Impulse USB

109 6 Positional Video Playback buttons and selections Pause Stop Play from Cursor Speed Pauses the video Stops the video Select to start the playback at the position of the cursor. If not selected, playback starts at the beginning of the trace. Note Before setting the playback speed, check the recorded frame rate (fps) stated below the eye video. Normal - eye video recorded at 30 frames per second can only be played back at normal speed. Slow - eye video recorded at 60 frames per second can be played back at normal or slow speed. Slower - eye video recorded at > 60 frames per second can be played back at normal, slow, or slower speed. Otometrics - ICS Impulse USB 109

110 7 Video Record/Playback 7 Video Record/Playback 7.1 Record When recording an eye video, there are 2 image size options: Full Image or Region of Interest (ROI). Full Image 110 Otometrics - ICS Impulse USB

111 7 Video Record/Playback Region of Interest (ROI) Note Click the Remarks window tab to enter remarks. For more information about using the editing tools, refer to Entering test remarks 19. Video Record buttons and selections Start Stop Start video recording Stop video recording Note There is no limit to the length of the video recording; however, the longer the video recording is the larger the file will be on the hard drive. Otometrics - ICS Impulse USB 111

112 7 Video Record/Playback Video Record buttons and selections Reconnect Goggles Reconnect goggles (software-to-hardware connection) as instructed by this error message: Reconnect Webcam Reconnect synchronized room video as instructed by this error message: Test Setup Full Image - select to record the full image ROI - select to record only the area inside the ROI box Vision Denied - select to indicate the recording was done with vision denied Eye Record Speed Options for recording Full Image: 30 fps 60 fps Options for recording ROI: 30 fps 60 fps 120 fps Compress eye video - select to reduce video file size Note If the video is recorded at 60 or 120 frames per second it can be played back in slow motion or at normal speed. At normal speed some frames will be skipped. The eye video can also be compressed. 112 Otometrics - ICS Impulse USB

113 7 Video Record/Playback Video Record buttons and selections Synchronized Room Video Recording Room Record Speed Mode (synchronized room video only) External Monitor Turn synchronized room video recording on and off. Room video is always compressed. Options for recording 15 fps 30 fps The higher the frame rate the larger the file size. Choose to record the video in color or grayscale. Color video creates a larger file size. To display the eye video on the computer monitor as well as on an external monitor, click. You can record eye video only or eye video with room video. If you chose to combine eye and room video, this example shows the resulting file size for a 20-minute recording. Eye Video (60 fps, compressed) Room Video (15 fps, grayscale) Eye Video Eye Video Size Room Video Size Combined Video File Size Time to Export Combined Video (minutes) ROI 120 MB 270 MB 1.51 GB Full Image 585 MB 270 MB 1.93 GB Otometrics - ICS Impulse USB 113

114 7 Video Record/Playback 7.2 Playback The list of videos that have been collected for the selected patient (including videos collected during head impulse testing) is displayed along with the following information about each video file: Date & Time - Date and time the video was collected Type - Indicates if the video was collected during head impulse testing (HI) or separately (VO = video only) - Indicates Vision Denied was selected for the recording fps - Frame rate at which the video was recorded (frames per second) - To mark a file for a specific purpose (for example, to indicate abnormal results), click in the check box under the column heading marked with this unique identifier. File Size (MB) - File size of the eye video. If the synchronized room video was used during recording, the file size is a combination of the eye and room video. Recording information is listed with the video: Date and time the video was recorded The current frame and the number of total frames Speed at which the video was recorded The time at which the current frame was recorded Note To conserve disk storage space, it is important to delete all videos that are not important. 114 Otometrics - ICS Impulse USB

115 7 Video Record/Playback Note To add or modify remarks, click the Remarks window tab. For information about the editing tools, refer to Entering test remarks 19. Video Playback buttons and selections Play Pause Stop Delete Video Plays the video Pauses the video Stops the video Deletes the video(s) for the selected test. Note It is recommended to delete videos that are not needed in order to save disk drive space. After a video(s) has been deleted, the video data cannot be recovered. Playback Speed Note Before setting the playback speed, check the recorded frame rate (fps) stated below the eye video. Normal - eye video recorded at 30 frames per second can only be played back at normal speed. Slow - eye video recorded at 60 frames per second can be played back at normal or slow speed. Slower - eye video recorded at 120 frames per second can be played back at normal, slow, or slower speed. Synchronized Room Video Choose to play the eye video with the synchronized room video. The room video is synchronized with the eye video at all speeds. Otometrics - ICS Impulse USB 115

116 8 Reports 8 Reports Click Reports. The Reports window (A) opens with the default report. The report includes the last set of data collected for that patient. Based on the data collected, this is the order of the separate test sections: Oculomotor, Head Impulse, and Positional. Note The reports are generated using vector based graphics. Vector based graphics provide exceptional print quality and are journal quality for publication submissions. The default report is automatically saved. To make changes to the current report, refer to Edit Report 117 and Review Report Options 119. Note To make changes to the default settings for all reports (such as which facility data and patient data are included), refer to Facility Info 138 and Report Options Otometrics - ICS Impulse USB

117 8 Reports 8.1 Edit Report Information can be added to the report by selecting from the report lists provided with the application: Note If any of the report lists do not display, re-import the missing list(s). Refer to Importing sample report lists 156. You can modify the symptoms, impressions and macros supplied with the application or create your own. Symptoms: From this list select symptom(s) the patient reports during the case history. Selected items are added to the report section titled Symptoms. Impressions: From this list select overall medical impression(s) based on the test results. Selected items are added to the report section titled Impressions. Macros: For each test performed, select overall finding(s) from this list to insert in the text field (A). Text seen in the text field is added to the report section titled Findings. Note If you prefer not to insert a macro, add overall findings by typing text in the text field. For information about using the editing tools, refer to Entering test remarks 19. Otometrics - ICS Impulse USB 117

118 8 Reports Selecting items from report lists From the Symptoms list and Impressions list, click each check box that applies. From the Macros list, click the name of the macro and click Insert. Note Some macros have text longer than what can be displayed in the list window. To see the entire text, roll the cursor over the macro name. 118 Otometrics - ICS Impulse USB

119 8 Reports Customizing report lists Note Report lists can be imported into one system, customized, and exported to other standalone workstation systems. This is useful when a facility has multiple standalone workstations. To customize report lists, click Symptoms, Impressions, or Macros. To rename a group or change the item text, click the item and make the desired change. To add a group, click Add Group and type in the name for the new group. To add an item, click a group name, click Add Item and type in the text for the new item. To rearrange the order of items in a group or the order of groups in a list, click the item or group name. Click Up or Down to move the item or group. To export the current report list, click Export. Change the file name and location as needed. Click Save. To delete an item or group, click the item or group, and click Delete. Click OK to permanently delete the item or group. When importing lists, select Remove Existing List to replace the existing list with the list to be imported. Select Keep Existing List to add list to be imported to the existing list. Note If a mistake is made, you can re-import the manufacturer-supplied list. After making changes, click Save to save the changes. Click Cancel to discard the changes. 8.2 Review Report Options If this is a new patient, the report in this window is the default report automatically created. For a patient with one or more reports, the Selected Report list displays all reports including the date and time of the report. A check mark in a test group column (test groups are represented by icons) indicates the report includes data for that test group (oculomotor, head impulse, positional). You can preview all of the reports for this patient. Otometrics - ICS Impulse USB 119

120 8 Reports You can make a new report that combines several test sessions and/or several test types into one report. To create a new report, click New. To delete an existing report, click the report name and click Delete. After the report has been deleted it cannot be recovered. To add a test to the report, click the test group tab and click the check box at the left of the test name in the Include Results From list. Clicking the check box again removes the test from the report. The Include Results From list is divided into 3 test groups: Oculomotor, Head Impulse and Positional. Tests are listed with the test date and time and test name. (The name is the test type and test direction.) Depending on the test, and what settings and remarks were added to the test, this information will also be provided: a check mark in this column (vision denied) indicates the test was performed with vision denied, a check mark in this column (unique identifier) if this was selected for the test, test remarks. For each test group, select the data elements to be included in the report. From the Select Report Options list, click Select All to include all options in the report the check box for each report option to be included, or Deselect All to not include any of the options in the report. Oculomotor Test Options Calibration Graph Includes a snapshot of the real time eye and head trace during the calibration check 120 Otometrics - ICS Impulse USB

121 8 Reports Oculomotor Test Options Horizontal Traces Includes a 10-second recording of the horizontal eye position trace centered around the cursor Note For SPV tests, the cursor is positioned in the middle of the culmination phase unless it has been moved to a different position in the analysis window. Vertical Traces a 10-second recording of the vertical eye position trace centered around the cursor Note For SPV tests, the cursor is positioned in the middle of the culmination phase unless it has been moved to a different position in the analysis window. Peak SPV Test Remarks the degrees per second of the slow-phase velocity peak as set in the analysis window for this trace (Applies only to SPV tests.) any test remarks in the patient file Head Impulse Test Options Calibration Graph Gain Graph Mean Gains Age Normative Data 2D Impulse graphs Large 2D Impulse graphs Saccade info Hex Plot Progress Data Includes a snapshot of the real time eye and head trace during the calibration check gain graph displayed in the 2D/3D window mean gain symbols on the gain graph as displayed in the 2D/3D window (values display by default) mean gain symbols and values on the gain graphs displayed in the progress data window age-based normative cutoff values defined as the mean ± 2 standard deviations eye (saccade and VOR) and head traces displayed in the 2D window eye (saccade and VOR) and head traces displayed in the 2D window printed larger than the selection 2D Impulse graphs number of overt, covert and total saccades in an individual head impulse test (e.g., left Lateral) include eye (saccade and VOR) and head traces and hex plot displayed in the Hex Plot window gain graphs displayed in the Progress Data window Otometrics - ICS Impulse USB 121

122 8 Reports Head Impulse Test Options Test Info Test Remarks Includes the numbers of the accepted and rejected head impulses from the collection and analysis algorithms as displayed in the Info window in the 2D/3D window, average frame rate, and information regarding factors affecting test analysis such as - Patient has Spontaneous Nystagmus (when Spontaneous Nystagmus was checked in the Test Setup window) - Catch-up Saccade Parameters Modified (if values were changed in the Reanalysis window) any test remarks in the patient file Positional Test Options Calibration Graph Horizontal Traces Vertical Traces Peak SPV Full Trace Window for Repositioning Test Remarks Includes a snapshot of the real time eye and head trace during the calibration check a 30-second recording of the horizontal eye position trace centered around the culmination phase or centered around the cursor when the cursor has been moved to a new position in the analysis window a 30-second recording of the vertical eye position trace centered around the culmination phase or centered around the cursor when the cursor has been moved to a new position in the analysis window the degrees per second of the slow-phase velocity peak as set in the analysis window for this trace the complete trace of the repositioning test any test remarks in the patient file 122 Otometrics - ICS Impulse USB

123 8 Reports 8.3 Report toolbar buttons The toolbar includes standard buttons for printing the report, saving a modified report, making a PDF file of the report, and ing the report. To change the magnification level of the page move the slider towards the zoom out (-) or zoom in (+) magnifying glass icon, or click the zoom out (-) or zoom in (+) magnifying glass icon. You can choose to display the report page using these buttons Fit Document to Width Fit Document to Height Fit Document to 100% After making a change, click Refresh to display the change. Otometrics - ICS Impulse USB 123

124 9 Patient Lists 9 Patient Lists The Patients window lists the patient data entered into the OTOsuite Vestibular Database. The Patients window also includes the ability to view patient information from the ICS Chartr Database and the Patient Export and Patient Import windows from which you can export data out of and import data into the OTOsuite Vestibular database. List operations Each list has rows with patient information separated into columns according to the type of information: Patient name (last and first), ID, etc. The column titled Last Tested lists when the most recent test data was collected. The column titled Last Modified lists the most recent date on which information in the patient file was changed. For some of the lists, checkmarks under these columns indicate the type of data collected for that patient: Oculomotor Head impulse Positional Videos Note The unique identifier symbol next to the checkmark indicates the user has chosen to mark one or more tests or videos for a specific purpose (for example, it may refer to abnormal results, results to be used for a study, etc.) Searching for a particular patient(s) The following rows are searchable: last name, first name, patient ID, Gender, DOB, and Physician. To search start typing in the row between the title and the first patient entry. Clear search field by clicking the clear button.. Selecting more than one patient Adding patients Select all patients: Click Select All. To deselect all selected patients, click Deselect All. Select a group of patients: Click the first name of the set, hold down the Shift key and click the last name in the set. Select individual patients: Keep the Ctrl key pressed as you click on each patient. Click New. Refer to New Patient 20 for instructions. 124 Otometrics - ICS Impulse USB

125 9 Patient Lists Deleting patients Click Delete to delete the patient(s). Note You will be prompted to confirm deletions of the patient(s). If you choose Yes the data is permanently deleted. There is no possibility to retrieve the patient(s). Reordering lists Changing column width Click the column header, to reverse the order. For example Click Patient Name to change the order from A-Z to Z-A. Click DOB to change the order from oldest-youngest to youngest-oldest. In the column heading of two adjacent columns, click the cursor on the line dividing two columns. The cursor changes to a double-headed arrow. Drag the cursor to increase or decrease the column width. 9.1 OTOsuite Vestibular Database From the Patients group, click Patient List. The window that opens provides access to all OTOsuite Vestibular patients. The column titled Last Tested lists when the most recent test data was collected. The column titled Last Modified lists the most recent date on which information in the patient file was changed. 9.2 Chartr Database From the Patients group, click ICS Chartr Patients. The window that opens provides access only to the list of patients in the Chartr database. Test data collected in Chartr VNG/ENG or EP can not be viewed in the OTOsuite Vestibular application. In order to reduce data entry time, patient's information in the Chartr database can be imported into the OTOsuite Vestibular database: 1. Select the patient(s) to be imported. 2. Click Import. 3. Click OK. Imported displays in the Status column to indicate the process was completed. The record of imported patients clears when the application is closed. The Chartr software must reside on the same computer as the OTOsuite Vestibular software for the database to be accessible. If the database is accessible, the ICS Chartr Patients item will appear in the navigation panel of the Patients group. 9.3 Patient Export From the Patients group, click Patient List. Click Export. The window that opens provides access to all OTOsuite Vestibular patients. The column titled Last Tested lists when the most recent test data was collected. The column titled Last Modified lists the most recent date on which information in the patient file was changed. To export one or more patients: Otometrics - ICS Impulse USB 125

126 9 Patient Lists 1. Select the patient(s). 2. Choose how data will be exported: XML Files & ASCII Raw Data - Select to export patient data that will be shared with another ICS Impulse system or used for electronic medical records. For each patient, the export includes both an XML file and an ASCII.txt file. For all test types except those in the Head Impulse group, the raw data in the *.txt file is required to view patient data in the ICS Impulse application. XML files contain complete patient data as stored in the database. ASCII raw data files contain the ICS Impulse test results. The *.txt files can be viewed for research using programs such as Excel or MatLab. When files are used outside of the ICS Impulse application, refer to Understanding raw data files 176 for an explanation of how to convert the data to a tabular format and a description of the resulting columns that vary according to the test group. PDF Reports - Select to export all reports for the patient(s) to be used for electronic medical records. ASCII Test Results - Select to export ICS Impulse test results formatted in a CSV - comma separated values - file to be used for research purposes with programs such as Excel or MatLab. Refer to Understanding raw data files 176. Combine Eye/Room Videos - Select to export the eye video and room video in one avi file. Due to the size of the file you can only select 1 patient at a time. On the supported operating systems for OTOsuite Vestibular the MJPEG codec is installed as default. To view this file on another computer you must have Windows Media Player installed and MJPEG codec. Note It is recommended to delete all videos that are not important from the patient file before exporting. To understand the increase in file size when combining room video with eye video, refer to 113. Anonymize Patient - Select to export data for sharing while keeping personal information private. For example, when Anonymize Patient is selected, the last name, patient ID, and file names are replaced with the word None. You can only select 1 patient at a time. Note Importing files for which Anonymize Patient has been selected: These files contain information that prevents the system from overwriting existing patient data. Only data added after the original export will be imported. If no existing patient data is present, None replaces all information that would identify the patient. 126 Otometrics - ICS Impulse USB

127 9 Patient Lists avor - Select to export eye and head position data to avor application. 3. Click Export or Export to Export will send the file to the location set up in the Administrator window of the System group. Export to will send the file to the location you select in the browse function. Exported displays in the Status column to indicate the process was completed. The record of exported patient(s) clears when the application is closed. 9.4 Patient Import Files can be imported from files previously archived, imported, or exported from the OTOsuite Vestibular application. 1. From the Patients group, click Patient List. Click Import. 2. Click Open Folder and navigate to the location of the files to be imported. Note In order to view the patient data both the *.xml and *.txt file must be imported. The only exception is Head Impulse data where the data can be viewed with only the *.xml file. 3. Click OK. 4. In the list of patient files, the patient name (last and first), ID, gender, date of birth are provided. Select the file(s) to import. 5. Click Import. Imported displays in the Status column to indicate the process was completed. The record of imported files clears when the application is closed. Click to update the list of patient files in the Import folder. Note Importing files for which Anonymize Patient has been selected: These files contain information that prevents the system from overwriting existing patient data. Only data added after the original export will be imported. If no existing patient data is present, None replaces all information that would identify the patient. Refer to Troubleshooting 163 for problems related to importing and/or viewing imported files. Otometrics - ICS Impulse USB 127

128 10 Options 10 Options These settings are available in the Options group: General (Refer to General 129.) Graph Colors (Refer to Graph Colors 132.) Oculomotor (Refer to Oculomotor 133.) Head Impulse (Refer to Head Impulse 135.) Positional (Refer to Positional 137.) Facility Info (Refer to Facility Info 138.) Report Options (Refer to Report Options 139.) In the Navigation Panel,the Options menu has two items: Test Options and Report Options. To view or change the General settings, click Test Options. To view or change all other test settings, click Test Options and then click the appropriate tab. To view or change report settings, click Report Options. 128 Otometrics - ICS Impulse USB

129 10 Options 10.1 General From the Options menu, click Test Options. Item Startup Module Choices Select one of the options to set which test data collection window is available when the application opens. Gaze VOR Skew Deviation Impulse Dynamic Repositioning Video/Record Playback Otometrics - ICS Impulse USB 129

130 10 Options Item Eye Video Record Speed Choices Head Impulse Select one of the options to set the video record speed when collecting eye video during head impulse testing 30 fps 60 fps 120 fps Note The higher the frame rate selected, the larger the data file will be. Oculomotor & Positional Select one of the options to set the video record speed when collecting eye video during testing. The setting is used for both Oculomotor and Positional testing. 30 frames/sec 60 frames/sec Max frames/sec Note Max is the maximum speed that can be collected and is dependent on the computer being used. The higher the frame rate selected, the larger the data file will be. Eye Video Compression Synchronized Room Video Recording Select On or Off. (The default setting is On.) Select one of the options to set the video record speed when collecting room video. 15 frames/sec 30 frames/sec Note The higher the frame rate selected, the larger the data file will be. Select one of the options to set the room video format. Color Grayscale Note Recording in color will create a larger data file to be stored. 130 Otometrics - ICS Impulse USB

131 10 Options Item Reconnect Choices Reconnect Goggles Reconnect the goggles (software-to-hardware connection) as instructed by this error message: Reconnect Synchronized Room Video Reconnect the room video camera (software-to-hardware connection) as instructed by this error message: Otometrics - ICS Impulse USB 131

132 10 Options 10.2 Graph Colors 1. From the Options menu, click Test Options. 2. Click the Graph Colors window tab. Item Eye 2D and 3D Hex Plot Head - Real Time Restore Defaults Choices VOR - change the default color of the VOR component of the eye trace in the 2D analysis and the entire eye trace in the 3D analysis. Saccade - change the default color for the saccade component of the eye trace in the 2D analysis. Change the default color of the head traces in the corresponding analysis windows. Change the default color of the mean gain bars. The color for each bar is determined by the unilateral cutoff values and by the upper limit of Change the default color of the head trace in the Real Time (collection) window. Click Restore to restore the default colors recommended by Otometrics. These colors are optimized for people with color blindness. 132 Otometrics - ICS Impulse USB

133 10 Options 10.3 Oculomotor 1. From the Options menu, click Test Options. 2. Click the Oculomotor window tab. Item Beats Averaged in Peak SPV Calc (3-10) Choices Select the number of SPV beats to be averaged for the velocity calculation in the SPV analysis. Choose from the list of available choices: 3 through 10 beats. Otometrics - ICS Impulse USB 133

134 10 Options Item Default Test Settings Choices Custom Name Change the name of the test from the default name to a new name. Maximum Duration (minutes) Select the minutes desired from the drop down list. Display Collection Traces Choose to display horizontal right (HR), vertical right (VR) traces or all traces. Display Analysis Traces Choose to display horizontal right (HR), vertical right (VR) traces or all traces. Head Position Feedback or Synchronized Room Video Head Position Feedback - displays an image of the head and records the position of the patient's head in space. It can be played back along with the data collection trace and eye video. Note Head Position Feedback is NOT available for VVOR and VORS because of the increased speed needed for the eye video and for Skew Deviation because the head is stationary during testing. Synchronized Room Video - records the room video. It can be played back along with the data collection trace and eye video. None - no visual image of head or room is recorded 134 Otometrics - ICS Impulse USB

135 10 Options 10.4 Head Impulse 1. From the Options menu, click Test Options. 2. Click the Head Impulse window tab. Default colors for data shown in the graphs allow those who are color blind to easily distinguish the different colors. To change the colors used for each type of data, click the Graph Colors window tab in the Options window. Refer to Graph Colors 132. Collection Settings Item Start Collection Automatically Required Impulses Operator Feedback Choices By default, this option is selected. Collection starts automatically x seconds after the collection window opens. Time is set in Delay to Start (seconds) field. Number of accepted impulses required in the Left Impulses and Right Impulses fields for Lateral and LARP/RALP in order for data collection to automatically stop. Feedback during Collection - turns on operator feedback in the Real Time Trace. Head Position Feedback - turns on operator feedback to monitor head position during test setup for LARP/RALP. Analysis Graphs Item X-Axis Display 2D Analysis Graphs Graph Position Choices Allows user to choose if they want the x-axis of the 2D graphs to display in milliseconds or samples. Allows user to swap the 2D and 3D graphs so that the left data graph is on the right side. Otometrics - ICS Impulse USB 135

136 10 Options Gain Graphs Item Lateral Cutoffs Choices Set cutoff lines Unilateral - the cutoff line between normal and unilateral loss Bilateral - the cutoff line between unilateral loss and bilateral loss LARP/RALP Cutoffs Set cutoff lines Unilateral - the cutoff line between normal and unilateral loss Bilateral - the cutoff line between unilateral loss and bilateral loss Restore Default Cutoffs Age Normative Data Restores the normative data cutoff values as documented in published data and recommended by Otometrics. (1) On or Off - If On is selected, age-related normative data displays in the gain graph. (2) Note The date of the birth of the patient must be entered into the patient information in order for it to display. The age norms include data from 10 years and older. Gain Points Change the size of the individual gain dots on the gain graphs. Increase the gain point size when presenting data on a video projector. (1) MacDougall HG, Weber KP, McGarvie LA, Halmagyi GM, Curthoys IS (2009) The video head impulse test: Diagnostic accuracy in peripheral vestibulopathy. Neurology 73 (14): (2) McGarvie L, Halmagyi M, Curthoys I, MacDougall H. Video head impulse testing age dependent normative values in healthy subjects. XXVIII Meeting of the Bárány Society, Buenos Aires, Argentina, May, Journal of Vestibular Research 24 (2-3), 77. Curthoys IS, McGarvie L, MacDougall H, Burgess A, Chiarovano E, de Waele C, Halmagyi M. The video head impulse test (vhit) of semicircular canal function; 1. Sensitivity and specificity for vestibular loss and 2. Age dependent norms in healthy subjects. Oral presentation S501 at the Neuro-Otology Society of Australia's 24th Annual Clinical and Scientific Meeting, 8-10 August, 2014, Royal Prince Alfred Hospital, Sydney, Australia. McGarvie L, MacDougall H, Chiarovano E, de Waele C, Curthoys I. The video head impulse test (vhit) of semicircular canal function: True sensitivity, specificity and age dependent norms in healthy subjects. Poster no. 2, presented at Frontiers 2014: The Art, Science and Future of Otorhinolaryngology, 30 July-1 August 2014, Sheraton on the Park, Sydney, Australia. Ian Curthoys, Leigh McGarvie, Hamish MacDougall, Ann M Burgess, Samanthi Goonetilleke, Michael Halmagyi, Elodie Chiarovano, Catherine de Waele Metrics of the Video Head Impulse Test (vhit) of Semicircular Canal Function; Sensitivity and Specificity for Detecting Known Vestibular Loss and Age Dependent Norms for vhit in Healthy Subjects. Accepted for 2015 Midwinter meeting of the Association for Research in Otolaryngology, Baltimore. Feb 22, Otometrics - ICS Impulse USB

137 10 Options 10.5 Positional 1. From the Options menu, click Test Options. 2. Click the Positional window tab. Item Beats Averaged in Peak SPV Calc (3-10) Test Settings Choices Select the number of SPV beats to be averaged for the velocity calculation in the SPV analysis. Choose from the list of available choices: 3 through 10 beats. Custom Test Name Change the name of the test from the default name to a new name. Maximum Duration (minutes) Select the minutes desired from the drop down list. Display Collection Traces Choose to display horizontal right (HR), vertical right (VR) traces or all traces. Display Analysis Traces Choose to display horizontal right (HR), vertical right (VR) traces or all traces. Head Position Feedback or Synchronized Room Video Head Position Feedback - displays an image of the head and records the position of the patient's head in space. It can be played back along with the data collection trace and eye video. Synchronized Room Video - records the room video. It can be played back along with the data collection trace and eye video. None - no visual image of head or room is recorded Otometrics - ICS Impulse USB 137

138 10 Options 10.6 Facility Info 1. From the Options menu, click Test Options. 2. Click the Facility Info window tab. Only users with Allow User to Change System Settings selected in their profile have access to certain fields in this window. The information entered here is used in the reports as specified in the Report Settings window. (Refer to Report Options 139). Enter text in the fields for the facility information and add a logo: Note The maximum number of characters is 32 for all fields except the facility name for which 45 characters are allowed. Logos are resized. 1. Click Browse Navigate to the location of the file to be used for the logo. 3. Select the file and click Open. To remove the logo, click Clear. 138 Otometrics - ICS Impulse USB

139 10 Options 10.7 Report Options 1. From the Options menu, click Test Options. 2. Click the Report Options window tab. Only users with Allow User to Change System Settings selected in their profile have access to certain settings in this window. Changes made to these settings affect all reports created after the changes are made. Note To make changes only to the current report, refer to Review Report Options 119. Settings Patient Information to be Printed in Reports Operator Names to be Printed in Reports Address Format in Printed Reports Black and White Printer Setting Options Select which items to include. Select to include either Operator who last updated the patient report, or Operator who collected test data, or both. Select Print postal code before city to insert the postal code before the name of the city/town/village. Select Unique Gain Graph symbols to change the symbol for left gain values so that it can be distinguished from the symbol for right gain values when using a black and white printer. Otometrics - ICS Impulse USB 139

140 10 Options Settings Facility Information to be Printed in Reports Options Select which items to include. Note To change the facility information, refer to Facility Info 138. Select Report Paper Size Select Letter or A4. Set Report Titles Change the default names of the main report title and section titles. 140 Otometrics - ICS Impulse USB

141 11 System Settings 11 System Settings Some System Settings windows are only accessible to those with a user profile that includes one or both of these choices selected: Add User as Administrator or Allow User to Change System Settings. Refer to Set up a new user Administrator Only users with Add User as Administrator selected in their profile have access to this window where user data can be created, edited, and deleted. The network locations are set for shared files (videos, reports (PDF), export, and import). For more information, refer to Changing the storage locations for videos, export, import, report PDFs 158 for more information. List operations The user data is separated into columns according to the type of information: Last name, first name, user name, etc Set up a new user Important Set up at least one user with administrator privileges. 1. Click New. 2. Enter data. Entries that cannot be left blank are marked with an asterisk (*). Note The password is case sensitive. Otometrics - ICS Impulse USB 141

142 11 System Settings 3. To allow access rights, click Add User as Administrator (A) or Allow User to Change System Settings (B). Add User as Administrator - all rights Allow User to Change System Settings - all rights except Add, edit, or delete users, Specify the network locations for shared files (video, reports (PDF), import, and export), and Update application license and firmware 4. Click Save to save the changes. Click Cancel to discard the changes Edit user data 1. Select the user from the list. 2. Click Edit Delete user 3. Edit the changes making sure all required fields marked with an asterisk (*) are completed. 4. Click Save to save the changes. Click Cancel to discard the changes. 1. Select the user from the list. 2. Click Delete. 3. Click OK Workstation Settings From the System group, click System Settings. Only users with Allow User to Change System Settings selected in their profile have access to certain fields in this window. Complete the fields with information provided by the system administrator. 142 Otometrics - ICS Impulse USB

143 11 System Settings Item Workstation Computer Name Workstation Location Installation Profile Client/Server Database Port Configuration Settings This read-only field displays the computer name as assigned in the Windows Control Panel User-defined name to describe the location of this PC Type of installation that was chosen during the software install process - standalone, server, client or both (server- /client) Port number used by the client to access the database on the network Server - the computer in the network responsible for receiving, routing and delivering messages From - the address from which s are sent To - default address to which the s are sent (the user has ability to change or add to this address) SMTP Port (Default = 25) This server requires a secure connection (SSL) Outgoing Account This defines the simple mail transfer protocol port (25 is most typically used) When selected, the security protocol SSL (Secure Sockets Layer) is used when sending an . Use default network credentials - uses the default network credentials to log into the server Log in with user name and password - uses the user name and password as specified in the fields below this choice to log into the server Select Program Language Reset Navigation Bar Use Operating System Language - when selected the OTOsuite Vestibular software will use the operating system language. If the operating system language is one that is not supported, the OTOsuite Vestibular software defaults to English. Instead of selecting Use Operating System Language choose from the list of languages. If changes had been made to the items in the navigation bar, click to reset the panel to the manufacturer default settings. Otometrics - ICS Impulse USB 143

144 11 System Settings 11.3 OTOsuite Vestibular Database Note If the database is located on a server, all users must be logged off of client workstations prior to performing an archive or backup of the data. Database management cannot be performed from a client workstation. From the System group, click System Settings. Only users with Allow User to Change System Settings selected in their profile have access to database functions. In this window both Archive (A) and Backup (B) functions are available. In addition, this window lists the database version, and the size and location of the OTOsuite Vestibular database file (C), information about raw data storage (the size and location of the file) (D) Note The actual size of the database may be smaller than what is shown here. The number of MB stated is the sum of the 1) space used by existing patient data and, 2) the space made available each time patient data is archived. Until all space made available from archiving is used, this figure may not change. 144 Otometrics - ICS Impulse USB

145 11 System Settings Archiving patient data When patient data no longer needs to be available in the OTOsuite Vestibular database, the data can be archived. To optimize performance, we recommended maintaining a maximum of 500 patients in the database. Any archived patient file can be imported back into the main database if needed. Important Archiving removes patient information, test data, video-related data and the AVI video clips from the OTOsuite Vestibular database. Select All Patients Patients with Last Tested Date between to archive all patients in the database only those patients with a last tested date within the date range selected Clicking Archive Now creates a backup of the full database, and then exports the selected files to the archive directory (c:\programdata\otometrics\otosuitev\archives), and finally removes from the database all files that have been archived. To cancel the archive process, click Cancel. Note An archived patient file can be re-imported using the import operation. Refer to Patient Import Auto-Backup An automatic backup is made according to the time interval set only when Enable Auto-Backup is selected. (By default, an automatic backup of the full database is made every seven days.) Backups files are stored at c:\programdata\otometrics\otosuitev\backup. Note To make a copy of patient data that includes the AVI video clips, export the patient data to a separate location. Refer to Patient Export 125. We recommend that an automatic backup is done at least every seven days. If desired, change the time between backups by entering the number of days in Auto-Backup Every _ Days. (Ensure that Enable Auto-Backup is selected.) The backup starts when the application is closed. This message displays: Otometrics - ICS Impulse USB 145

146 11 System Settings The previous backup is renamed and saved along with the new backup: The previous backup file is renamed to old_autobackup_otosuitevdb.bak A new backup file named AutoBackup_OTOsuiteVDB.bak is created Note After a backup is made, the patient information, test data, and video-related data remain in the OTOsuite Vestibular database. To reduce the size of the database and secure patient data outside of the main database, we recommend archiving. Refer to Archiving patient data Preventing data loss (standalone installations) For standalone installations, at least once a month, copy the most recent backup and an export of all patient files to an separate location outside of the main database. 1. Open OTOsuite Vestibular. 2. Make a backup. Refer to Auto-Backup Export all patient files. Refer to Patient Export Double-click on the desktop shortcut OTOsuiteV Files>. 5. Navigate to the Backups folder and copy the most recent backup to the separate location. 6. Navigate to the Exports folder and copy all files to the separate location GDT Interface From the System group, click System Settings. Only users with Allow User to Change System Settings selected in their profile have access to fields in this window. The GDT interface is based on the documented GDT standard used only in Germany. When enabled the interface allows file transfers between a German practice management system (PMS) and the OTOsuite Vestibular system. The external PMS system can be used to launch the OTOsuite Vestibular system and open (or create) a specific patient. Once the impulse test is complete, a report is returned to the PMS system. To enable the GDT interface to a Practice Management System, select the check box Enable GDT Interface to Practice Management System. 146 Otometrics - ICS Impulse USB

147 11 System Settings Item OTOsuite Vestibular System Name PMS System Name Test Type File Transfer Timeout (secs) Character Set GDT Local File Transfer Directories Settings User-defined name. Limited to 4 characters. Used as part of the filename to identify the OTOsuite Vestibular system. User-defined name. Limited to 4 characters. Used as part of the filename to identify the PMS system. GDT-defined code used for file transfers to the Practice Management System. Limited to 6 characters. Limit for the number of seconds OTOsuite Vestibular will attempt to obtain a file written by PMS. ASCII - standard character set ANSI - character set includes accented letters and other non- English language characters Incoming Messages - specifies the folder location for incoming GDT messages. The OTOsuite Vestibular system picks up messages from this folder. The specified folder must exist. Click Browse... to select the folder. Outgoing Messages - specifies the folder location for outgoing GDT messages. The OTOsuite Vestibular system places message here to be picked up by the PMS system. The specified folder must exist. Click Browse... to select the folder About From the System group, click System Settings. Refer to this window to obtain specifications about the OTOsuite Vestibular and component software Software license The OTOsuite Vestibular application is stored on the computer. The goggles can be used with any computer on which the application has been installed. The OTOsuite Vestibular application determines which licensed features are available each time the goggles are connected. The Features list shows all licensed features. This procedure updates the software license. 1. From the System group, click System Settings. 2. Click About. Note Update License is disabled for all users except those with administrator privileges. 3. Click Update license. 4. Locate the new license file and click Open. Otometrics - ICS Impulse USB 147

148 11 System Settings Goggles firmware When the goggles are connected to the computer, Firmware version shows the current version of firmware. This procedure updates the goggles firmware using the *.otofw file. Note Before starting the procedure, ensure that you know the location of the firmware file. Only those with administrator privileges can use this procedure. 1. From the System group, click System Settings. 2. Click About. 3. Click Update firmware. 4. Browse to locate the firmware file, select the file, and click Open. 5. A series of messages report the status of the upgrade process. Click OK when this system message appears: 6. As instructed, disconnect and reconnect the goggles and restart the application Error Logs From the System group, click System Settings. Item Workstation Computer Name Workstation Location This read-only field displays the computer name as assigned in the Windows Control Panel User-defined name to describe the location of this PC 148 Otometrics - ICS Impulse USB

149 11 System Settings Item System Logging Location where system error log files are stored. Allow Anonymous Usage Statistics Copy Logs Click to enable/disable Eqatec. Eqatec gathers computer information and unhandled exceptions. This information can help us understand problems and resolve them in future revisions. Refer to Start installation 151 for more information. Click to make a copy of all log files and place them in the stated location. Debug Tracing Enable Debug Tracing If checked turns on debugging level debug tracing Overwrite Existing Debug Files Trace Categories (comma separated): Other Options: Check to overwrite trace file each time the application is started. If unchecked, trace data will be appended to the current file. Fields filled in with information provided by Otometrics support. Reserved for Otometrics use Location where debugging files are stored. Caution Debugging and error tracing should not be used unless instructed by Otometrics representatives or support staff. Otometrics - ICS Impulse USB 149

150 12 Software Procedures 12 Software Procedures 12.1 Installation and Setup Important The previous version of goggles (those with firewire and USB connections) are not compatible with OTOsuite Vestibular versions 2.0 or later. This section describes all steps required to complete the ICS Impulse System setup: Installing OTOsuite Vestibular software Connecting the goggles Installing the synchronized room video Importing sample report lists (not required for server-only installations) Importing demo data Customizing for your facility Installing Adobe Reader Setting up a networked database and workstation (not required for standalone installations) Minimum computer requirements Operating System CPU Memory Disk Space Connectors DVD Drive Monitor Components 64-bit: Windows 8 Pro, Windows 7 Professional & Enterprise 32- bit: Windows 8 Pro, Windows 7 Professional & Enterprise Intel i5 processor 64-bit (Windows 8 or Windows 7): 6 GB 32-bit (Windows 8, Windows 7): 4 GB 300 GB Up to four USB 2.0 or USB 3.0 for the goggles, synchronized room video, presentation remote, and external monitor Optional VGA port to connect an external monitor DVD R/W 1600 x 900 Screen resolution Mouse, keyboard Presentation remote - compatible models A separately purchased presentation remote can be used with the OTOsuite Vestibular application for various functions. Refer to Presentation remote 11 for a list of available functions. These presentation remotes have been tested and are compatible with the application: Logitech Wireless Presenter R Otometrics - ICS Impulse USB

151 12 Software Procedures Kensington Wireless Presenter Targus Laser Presentation Remote These presentation remotes are NOT recommended based on testing: Gyration Air Mouse and Remote Point. Only the most common presentation remotes were tested. There may be other remotes that are compatible with the OTOsuite Vestibular application Software Installation Start installation Note Possible error messages and what to do if they appear: - Firewall messages: Please allow access. - User Account Control (UAC) message: For Windows 7 and Windows 8 systems, a message that refers to the User Account Control (UAC) may display. Accept this message as it does not indicate a problem. - Microsoft Webcam or SQL Server error messages: If Microsoft has installed new Window updates, and the computer has not been rebooted, an error message may appear. Please reboot your PC and restart the software installation. 1. Save any files currently open and quit all programs. 2. Insert the OTOsuite Vestibular DVD. Note If the computer is set up to AutoRun, the installation starts. If AutoRun is not initialized, browse the DVD to find this icon. 3. Click setup. (You may need to close the DVD content folder.) 4. If you have Windows 7 or Windows 8, a security dialog will appear. Click Yes. 5. Installation of OTOsuite Vestibular requires certain applications (such as Windows Installer) to be installed on the computer. If an application(s) is missing, a dialog box lists the missing application(s). - Click Install. When the application(s) has been installed, the computer will restart. - Log in to computer. The installation continues automatically. 6. The Welcome screen appears. Click Next. 7. Select I accept the terms in the license and click Next. 8. The Anonymous Usage Statistics screen displays. Click Next. Note The Eqatec application is installed by default. It can be turned off in the Error Logs window of System Settings. If connected to the Internet, Eqatec gathers computer information and unhandled exceptions. This information can help us understand problems and resolve them in future revisions. No patient information or any information that would identify the facility or the exact computer is collected. Again, this information is only collected if the computer is connected to Internet. Otometrics - ICS Impulse USB 151

152 12 Software Procedures Note During the installation of OTOsuite Vestibular, you will see references to various other associated programs that are being installed. These other programs include: SQL Server (OTOsuite Vestibular database), Access Database Engine (supports the Chartr database), and Infragistics (reporting) Choose installation type OTOsuite Vestibular can be installed in a client/server or standalone configuration. In client/server, a single server hosts the database for one or more client workstations where the OTOsuite Vestibular application is installed. We recommend client/server installs to be set up using network domains. Use of workgroups is not recommended because it will require the same user name and password be used on each computer. In standalone a single computer hosts both the database and the OTOsuite Vestibular applications. Choose how OTOsuite Vestibular will be installed: Standalone installation Hosts SQL database and OTOsuite Vestibular application (no additional clients) Select Standalone and click Next. Continue at Complete the installation 153. Network installation - Server Hosts SQL database and a limited version of the OTOsuite Vestibular application (The limited version supports patient management (create, import, and export patients), system settings changes and database management. It does not allow viewing tests or collecting test data.) Continue to Server/Both installation 152. Network installation - Client Hosts OTOsuite Vestibular application Continue at Client installation 153. Network installation - Both (Client/Server) Hosts SQL database and OTOsuite Vestibular application. Can support additional clients. Continue to Server/Both installation Server/Both installation Before starting the installation, determine the type of installation required: Server only - OTOsuite Vestibular database and a limited version of OTOsuite Vestibular software for archiving/backing up data will be installed. Important When installing a server/client installation the server must be installed first. Both (Server and Client) 1. Select Server or Both and click Next. Note Although it is possible to change the port number (used by the SQL server), we recommended you use the one supplied on the screen. 2. Make note of the entries for Port Number and Server Computer Name as this information will be required for all client computers. (For computers connected to a printer, you can click Print to print out the information.) 152 Otometrics - ICS Impulse USB

153 12 Software Procedures 3. If Both was selected, click Next and continue at Complete the installation If Server was selected, click Next and continue at Complete the installation Client installation 1. Select Client and click Next. 2. Enter the port number and the server computer name obtained from the server installation. 3. Click Next and continue at Complete the installation Complete the installation 1. Click Install. A status window appears reporting the progress of the installation. 2. Click Finish. 3. Open the Control Panel. Windows 7 Windows 8 A. Press the Windows key. B. Start typing control panel until the option Control Panel appears. C. With Control Panel selected, press Enter. A. Press the Windows key + X. B. Select Control Panel from the list of options and press Enter. Note The Windows key is located next to the Alt key. It can be identified by the Windows logo on the key. In case the keyboard lacks this key, pressing Ctrl+Esc performs the same function. 4. Set the DPI to 100%. Windows 7 Windows 8 A. Click Display. A. Click Display. B. Select 100%. C. Click Apply. B. Select 100%. C. Click Apply. 5. For server-only installations, continue at Importing demo data For all other installations, continue at Connecting the goggles Connecting the goggles Note The current version of software does not support the previous version of the goggles where the connection to the computer was through an interface box. The current version of goggles has a single USB cable that connects directly to the computer. 1. Remove the cover from the lens of the goggles. Otometrics - ICS Impulse USB 153

154 12 Software Procedures Note Keep the cover. When the goggles are not in use, put the cover back on to prevent dust from accumulating on the lens. 2. Connect the USB cable to the 2.0 USB connector on the computer. Note Installing the driver for the goggles takes a few minutes. The message Hardware not found displays in the status bar until the driver is fully installed. A new driver is installed each time new goggles are connected to the USB port or if the goggles are moved to a new USB port. 3. Continue to Installing the synchronized room video Installing the synchronized room video Important Start the procedure with the synchronized room video disconnected. 1. Go to: 2. Select the operating system (A). 3. Download the LifeCam file. For example, if you choose Windows 7, download LifeCam bit and 64-bit for Windows 7 (B). 4. Double-click the LifeCam executable file (.exe) and follow the instructions. 154 Otometrics - ICS Impulse USB

155 12 Software Procedures Note Possible error messages and what to do if they appear: Microsoft Webcam or SQL Server error messages: If Microsoft has installed new Window updates, and the computer has not been rebooted, an error message may appear. Please reboot your PC and restart the software installation. 5. When the synchronized room video installation is finished, if setting up an external monitor, continue at Setting up an external monitor 155. Otherwise click sample report lists 156. (OTOsuiteV icon found on the desktop) to open the application and continue at Importing Setting up an external monitor 1. With the external monitor connected to the computer, open the Control Panel. Windows 7 Windows 8 A. Press the Windows key. B. Start typing control panel until the option Control Panel appears. C. With Control Panel selected, press Enter. A. Press the Windows key + X. B. Select Control Panel from the list of options and press Enter. Note The Windows key is located next to the Alt key. It can be identified by the Windows logo on the key. In case the keyboard lacks this key, pressing Ctrl+Esc performs the same function. Otometrics - ICS Impulse USB 155

156 12 Software Procedures 2. Open Display and click Adjust Resolution. Ensure the computer monitor is identified as the main monitor (1) and select Extend these displays. A. Click Display. Windows 7 & Windows 8 B. Click Adjust Resolution. C. Verify that 1 & 2 monitors are identified as shown here. If not click Detect. D. Select Extend These Displays. E. Click OK. 3. Click (OTOsuiteV icon found on the desktop) to open the application. 4. Click. 5. Click on the title bar of the new window title and drag the window to the external monitor. 6. Click the small box in the top right corner to display the window as large as possible. 7. The settings are retained after closing OTOsuite Vestibular and restarting the application Importing sample report lists These sample report lists can be imported: Symptoms, Impressions, and Macros. 1. In the navigation panel, from the Reports menu, click Reports. 2. If the Edit Report window is not displayed, click Edit Report. 3. Click Symptoms..., Impressions..., or Macros Click Import. 156 Otometrics - ICS Impulse USB

157 12 Software Procedures 5. Click the appropriate file in the correct language to import: Impulse Symptoms, Impulse Impressions, or Impulse Macros. 6. Click Open. 7. Click Save. Note If you are upgrading and adding a module (for example, LARP/RALP), it is recommended that you reimport the impressions and macros. All customizations to the previously imported impressions and macros will be maintained Importing demo data Note The demo data can be imported giving you the ability to view patient data and analysis for various diagnoses. 1. If the Patients window is not open, click Patient List. 2. Click Import. 3. Click Open Folder. The Import folder is highlighted. 4. Below the Import folder click the Demodata folder and click OK. 5. Select all patient files that appear in the Patient Import window. 6. Click Import. 7. Click OK. Note If you are upgrading and adding a module (for example, LARP/RALP), it is recommended that you import any new demo data files. This will assist you in learning the new module Customizing for your facility For standalone installations, enter facility specific information at each workstation where the software is installed. For network installations, facility-specific information entered at one client station will change the information at all client stations. Note For the initial login, the OTOsuite Vestibular provides a default user name and password. After one user with administrator privileges has been added, this default user name and password are no longer provided (the fields are blank). Use the new user name and password for subsequent logins. 1. From the System menu, click System Settings. 2. Click the Administrator window tab to set up a user and give this user administrator privileges. Refer to Administrator Click Workstation Settings window tab and select the desired program language from the list. 4. Click Yes to restart the application and complete the language change. Otometrics - ICS Impulse USB 157

158 12 Software Procedures 5. From the Options menu, click Test Options. 6. Click the Facility Info window tab and add the facility information. Refer to Facility Info Click the Report Options window tab to modify the settings such as the postal code position or paper size. Refer to Report Options Installing Adobe Reader For access to the digital version of the Reference Manual, Adobe Reader must be installed on the computer. Install the copy provided on the OTOsuite Vestibular DVD if required. 1. Browse the DVD to locate the Adobe Reader file. 2. Double-click Adobe Reader to start the installation and follow the on-screen instructions. 3. The installation is complete for standalone installations. For all other installations, continue to Changing the storage locations for videos, export, import, report PDFs Changing the storage locations for videos, export, import, report PDFs Note This procedure is for Client or Both (Client/Server) installation types. Ensure that the permission level for the folder is set for sharing before continuing. (Refer to Set sharing properties for new storage location 159 to set the permission level.) Users that have Add User as Administrator selected in their profile can use this procedure to change where files are stored. Note When OTOsuite Vestibular is installed as a networked installation, default storage locations for video and report files are set up on the server computer to be shared by all client stations. Default locations for export and import files are set up on each individual client station. 158 Otometrics - ICS Impulse USB

159 12 Software Procedures 1. Click System Settings and click Administrator. 2. Click Browse... to browse to the desired folder. Note If selecting a folder on the network, ensure that the folder you select is configured for sharing. 3. Select the folder and click OK. The new location for the folder displays in the OTOsuite Vestibular Storage Locations window. Note For each location that has been changed, new files will be stored at the new location. For example, if the location has been changed for video files, new video recordings will be stored at the new location. For each new location, existing files should be moved from the previous location to the new location. Set sharing properties for new storage location When the new storage location is set to a folder not configured for sharing, follow the procedure below: 1. Navigate to the required directory. 2. Right-click the folder selected for the new storage location. 3. Click Share with. Choose Specific people. 4. Choose names. 5. Click in the field next to the Add button. 6. Type in the name and click Add. 7. To change the permission, click the user name to highlight it. 8. Click the drop-down arrow at the right and click Read/Write. Otometrics - ICS Impulse USB 159

160 12 Software Procedures 9. Repeat steps 7 and 8 until Read/Write has been set for all users added to the list. 10. Click Share. 11. Click Done Uninstalling 1. Open the Control Panel. Windows 7 Windows 8 A. Press the Windows key. B. Start typing control panel until the option Control Panel appears. C. With Control Panel selected, press Enter. A. Press the Windows key + X. B. Select Control Panel from the list of options and press Enter. Note The Windows key is located next to the Alt key. It can be identified by the Windows logo on the key. In case the keyboard lacks this key, pressing Ctrl+Esc performs the same function. 2. Uninstall OTOsuite Vestibular. Windows 7 Windows 8 A. Click Programs and Features. A. Double-click Uninstall a program. B. Select the program to be uninstalled. C. Click Uninstall. D. Click Yes to all remaining questions. B. Select the program to be uninstalled. C. Click Uninstall. D. Click Yes to all remaining questions. Note Uninstalling the software will remove the OTOsuite Vestibular program but not other programs that were part of a previous OTOsuite Vestibular installation (for example, the SQL Server, National Instruments etc.) Upgrading When upgrading the OTOsuite Vestibular application, it is not possible to change the type of installation previously chosen. Contact your local representative if you need to make changes to the type of installation. Important When upgrading a server/client installation the server must be upgraded first. 160 Otometrics - ICS Impulse USB

161 12 Software Procedures Note It is recommended to export all patient data that has not been archived prior to an upgrading the software. Note If firewall messages appear, please allow access. 1. Save any files currently open and quit all programs. 2. Insert the DVD received with the upgrade of OTOsuite Vestibular application. Note If the computer is set up to AutoRun, the installation starts. If AutoRun is not initialized, browse the DVD to find this icon. 3. Click setup. (You may need to close the DVD content folder.) 4. Click Yes to the question in the security dialog. 5. The Welcome screen appears. Click Next. 6. Select I accept the terms in the license and click Next. 7. The Anonymous Usage Statistics screen displays. Click Next. 8. Continue to click Next until the Ready to Install screen appears. 9. Click Install. 10. Click Finish Reinstalling When reinstalling the OTOsuite Vestibular application, it is not possible to change the type of installation previously chosen. Contact your local representative if you need to make changes to the type of installation. Note If firewall messages appear, please allow access. 1. Save any files currently open and quit all programs. 2. Insert the DVD used when installing OTOsuite Vestibular previously. Note If the computer is set up to AutoRun, the installation starts. If AutoRun is not initialized, browse the DVD to find this icon. 3. Click setup. (You may need to close the DVD content folder.) 4. If you have Windows 7 or Windows 8, a security dialog will appear. Click Yes. 5. The Welcome screen appears. Click Next. 6. The Program maintenance screen appears. Click Next. Otometrics - ICS Impulse USB 161

162 12 Software Procedures 7. The Remove the Program screen appears. Click Remove. 8. Click Finish. 9. Click setup. 10. If you have Windows 7 or Windows 8, a security dialog will appear. Click Yes. 11. The Welcome screen appears. Click Next. 12. Select I accept the terms in the license and click Next. 13. The Anonymous Usage Statistics screen displays. Click Next. 14. Continue to click Next until the Ready to Install screen appears. 15. Click Install. 16. Click Finish. 162 Otometrics - ICS Impulse USB

163 13 Troubleshooting 13 Troubleshooting Calibration Problem Laser beam dots not seen on the wall or other projection surface Solution Make sure the light is not obstructed by hair or reflecting off another object in the line of projection. If obstruction is ruled out, call Technical Support. Caution Do not look directly at the lasers. Use of controls or adjustments, or performance of procedures other than those specified herein, may result in hazardous radiation exposure. Run button is disabled. In the Test Setup window for all Impulse tests: Lateral, LARP or RALP, ensure Lateral test is selected prior to calibrating. for the Oculomotor Gaze test, all Dynamic tests, and all Repositioning maneuvers, ensure Vision Denied is deselected prior to calibrating. Eye image Eye image not displayed If goggles were initially found, reconnect the USB cable to the computer and click ReconnectGoggles in ImpulseOptions (part of the Head Impulse group). If goggles were never found, close the software, reconnect the USB cable and relaunch the software. Test selections Eye image is seen but the test selections are disabled (grayed out). The status bar message indicates the goggles license is not installed. Contact your Otometrics customer support or Hotline to obtain a goggles license. Otometrics - ICS Impulse USB 163

164 13 Troubleshooting Playing video files Problem When using Windows 7 operating system, the following error dialog may be seen when trying to play a saved video file directly from Windows Media Player. This is done by either selecting the video file from Windows Media Player or by double-clicking on the video file from Windows Explorer. Solution To correct this problem, locate the file Win7- codecs v281.exe inside the folder Tools on the OTOsuite Vestibular installation DVD. Double-click the file to start the installation program and follow the prompts. Collection When the synchronized room video starts streaming video, a dialog appears on top of the image. Video pauses during play Frame rate too slow for accurate data collection (Error message appears during collection.) An installed application is attempting to take control of the video streaming. Disable the application. (The method for disabling will vary according to the particular application.) For client/server installations, the video will not play properly if the client and server are communicated through a wireless connection. The computer processor is too slow for acquiring the minimum frame rate needed for head impulse testing. Verify that the computer meets minimum specifications Close other software programs Disable wireless Internet Verify that computer is powered by the wall outlet (not powered by the battery) Verify power options are set appropriately (Refer to Set power options 182) As a last resort, disable Show Pupil Crosshair on Image (located in the Options window of the Head Impulse group) 164 Otometrics - ICS Impulse USB

165 13 Troubleshooting Collection Head Impulse Problem Head Position Feedback - On startup the image of the head drifts slowly clockwise. The Left, Right and Rejected counts are different in Impulse Test as compared to Left, Right and Rejects counts in 2D and 3DAnalysis Solution After starting the application (or pressing Reconnect Goggles), allow the goggles to sit for 2-3 minutes prior to placing them on the patient. This allows the sensors providing head position data to stabilize. Counts result from two separate algorithms that in combination assure that only quality data are analyzed. Collection window of Impulse Test: The counts are the result of the Collection algorithm that assesses the head velocity data and rejects invalid head impulses. Refer to Head Impulse Collection and Analysis algorithms 175. Analysis Head Impulse Importing patient data Trace shows saccade for which there is no saccade latency reported. Information Missing message is listed in the Status column Patient file does not appear in the list Info window of 2D and 3DAnalysis: The Analysis counts are the result of the Analysis algorithm that assesses all the data a second time. This algorithm may reject data accepted by the Collection algorithm (displayed in the Collection column) if the corresponding eye velocity data is not valid. (For example, when the tester performed an acceptable head impulse but the patient looked away from the fixation dot.) The saccade occurred prior to 70 ms and most likely is due to the goggles slipping. This message displays if the imported patient data is incomplete. The missing information will be noted in the applicable column (s) with this message: <Information Missing>. When the message appears only in the Status column, the missing information is the ASCII raw data *.txt file. The imported patient ID is missing in the imported patient file. Otometrics - ICS Impulse USB 165

166 14 ICS Impulse System Safety 14 ICS Impulse System Safety This manual contains information and warnings, which must be followed to ensure the safe performance of the devices and software covered by this manual. Local government rules and regulations, if applicable, should also be followed at all times. GN Otometrics ICS products are not designed to be used in conjunction with any devices not approved by GN Otometrics. Summation of combined unapproved parts could result in increased electrical leakage. All parts of the ICS Impulse system are suitable for use within the patient environment. When the ICS Impulse System is used in conjunction with a test device, make sure that all information, cautions, and warnings in the manual for the test device are followed. For safety specifics concerning test modules and test devices, see the specific manuals Symbols used ICS Impulse System CAUTION: Laser radiation. Do not stare into beam. Class 2 laser product. Consult user manual for warnings and cautions. Follow instructions for use. Complies with Type B requirements of EN MEDICAL - General Medical Equipment as to electrical shock, fire and mechanical hazards only in accordance with UL , first edition, 2003 CAN/CSA No M90. Electronic equipment covered by the Directive 2002/96/EC on waste electrical and electronic equipment (WEEE). All electrical and electronic products, batteries, and accumulators must be taken to separate collection at the end of their working life. This requirement applies in the European Union. Do not dispose of these products as unsorted municipal waste. You can return your device and accessories to Otometrics, or to any Otometrics supplier. You can also contact your local authorities for advice on disposal. Complies with Medical Devices Directive 93/42/EEC and RoHS Directive (2011/65/EC). 166 Otometrics - ICS Impulse USB

167 14 ICS Impulse System Safety ICS Impulse System Suitable for direct current only. (Applies to the goggles.) Complies with Class II requirements of the safety standard IEC Label locations A. B. C. D. LASER RADIATION WAVELENGTH DO NOT STARE INTO BEAM 660 nm CLASS 2 LASER PRODUCT OUTPUT POWER IEC : mw E. Otometrics - ICS Impulse USB 167

168 14 ICS Impulse System Safety 14.3 Safety notes 1. There are no user-serviceable parts inside the ICS Impulse System goggles. For the sake of safety and in order not to void the warranty, service and repair of electro-medical equipment should be carried out only by the equipment manufacturer or by service personnel at authorized workshops. In case of any defects, make a detailed description of the defect(s) and contact your supplier. Do not use a defective device. 2. Keep the unit away from liquids. Do not allow moisture inside the unit. Moisture inside the unit can damage the instrument and it may result in a risk of electrical shock to the user or patient. 3. Do not use the instrument in the presence of flammable agents (gases) or in an oxygen-rich environment. 4. A Class 2 Laser product is used for calibration. The laser beam projects from the front of the goggles onto a solid surface. Caution Do not look directly at the lasers. Use of controls or adjustments, or performance of procedures other than those specified herein, may result in hazardous radiation exposure. 5. It is recommended to install the unit in an environment that minimizes the amount of static electricity. For example, anti-static carpeting is recommended. 6. No parts may be eaten, burnt, or in any way used for purposes other than the applications defined in the Intended Use section of this manual. 7. The device can be disposed of as normal electronic waste, according to local regulations. 8. For safety reasons, accessories connected to the equipment's outlet fittings must be identical to the type supplied with the system. 9. The device is disconnected from the mains by removing the USB cable. 10. Do not touch non-medical parts, such as the laptop/computer or printer and the patient at the same time. 11. Exposure to electromagnetic fields can result in interference with the process of recording correct measurements. ICS Impulse System cameras and gyroscopes are sensitive to electrical disturbances. Avoid static discharges and electromagnetic fields. 12. No defibrillators or high-frequency surgical equipment should be applied to the patient when connected to the ICS Impulse System at any time. 13. Immediately discontinue use of the equipment if skin irritation or discomfort occurs. 14. Installation of any third party software (applications, programs, or utilities) other than those specified by GN Otometrics can compromise the safety or effectiveness of this system. 168 Otometrics - ICS Impulse USB

169 14 ICS Impulse System Safety 15. The ICS Impulse System needs to be installed and put into service according to the EMC information provided in this manual. Portable and mobile RF communications equipment can affect medical electrical equipment. The ICS Impulse System may be interfered with by other equipment with CISPR emission requirements. 16. The use of accessories and cables other than those specified for this device may result in increased emissions or decreased immunity of the ICS Impulse System. Refer to Accessories The ICS Impulse System should not be used adjacent to or stacked with other equipment and that if adjacent or stacked use is necessary, the equipment or system must be observed to verify normal operation in the configuration in which it will be used. 18. A small cooling fan is inside the goggles housing. In the unlikely event of the cooling fan vent being blocked, the temperature of the goggles surface in contact with the patient may rise to 42.2 C. 19. Warning notes: When connecting equipment to the USB connectors, the following must be considered: Equipment must be certified to relevant EN/IEC safety standards, e.g. EN/IEC Use of connected equipment in a patient environment, see Note 1. Ensure that the medical electrical system complies with the requirements of EN or IEC (2005), 3. ed. Note 1: The ICS Impulse system is a part of an medical electrical system. When assembling an medical electrical system, the person carrying out the assembly must take into account that connecting other equipment that does not comply with the same safety requirements as the ICS Impulse system may lead to a reduction in the overall safety level of the system. The ICS Impulse system is designed to ensure compliance with requirements in EN or IEC (2005), 3. ed. when the PC, printer, etc. are placed out of reach of the patient, i.e. not closer than approx. 1.5 meters/5 ft Manufacturer GN Otometrics A/S Hoerskaetten 9, 2630 Taastrup Denmark ( Responsibility of the Manufacturer The manufacturer is to be considered responsible for effects on safety, reliability, and performance of the equipment only if: All assembly operations, extensions, re-adjustments, modifications or repairs are carried out by the equipment manufacturer or personnel authorized by the manufacturer. The electrical installation to which the equipment is connected complies with EN/IEC requirements. The equipment is used in accordance with the instructions for use. The manufacturer reserves the right to disclaim all responsibility for the operating safety, reliability and performance of equipment serviced or repaired by other parties. Otometrics - ICS Impulse USB 169

170 15 Technical Specifications 15 Technical Specifications 15.1 ICS Impulse System ICS Impulse is type 1085 from GN Otometrics A/S Interface USB 2.0 or 3.0 to PC Power Supply Device is powered through USB (5 V DC, 500 ma) Performance Characteristics Inputs Sampling Rate Monocular (Right eye) 250 fps - Impulse, VOR, Video Record/Playback 173 fps - Gaze, Skew Deviation, Dynamic, Repositioning Video Recording Eye Tracking Software 30, 60 or 120 Hz Impulse, Gaze, VOR, Skew Deviation, Dynamic, Repositioning, Video Record/Playback 100 x 100 pixels - Impulse, VOR, Monocular Video Frenzel (ROI) 160 x 120 pixels - Gaze, Skew Deviation, Dynamic, Repositioning 376 x 240 pixels - Monocular Video Frenzel (Full Image) Windows Graphical User Interface; High Performance Analysis Software; Database Storage of Test Data; Sophisticated Patient and Test Data Management; Vision Denied for Testing in Complete Darkness Laser specifications Wavelength Output power Maximum 660 nm Maximum 0.9 mw Warm-up time <1 min Operating Mode Continuous operation Do not use the equipment in the presence of flammable anaesthetics (gases). 170 Otometrics - ICS Impulse USB

171 15 Technical Specifications Dimensions Goggles Length 7.25 in (18.4 cm) Width 0.5 in (1.3 cm) to 1.75 in (4.4 cm) Height 1.75 in (4.4 cm) Weight Goggles 2.1 oz (60 g) Calibration Calibration of the system is not required Classification Class II Type B Operating Environment Temperature +15 C to +29 C (59 F to F) Rel. Humidity 30 to 90%, non-condensing Air Pressure 700 hpa to 1060 hpa Operations at temperatures below -20 C (-4 F) or above +60 C (140 F) may cause permanent damage to the device. Storingand Handling Temperature -20 C to +60 C (-4 F to +140 F) Rel. Humidity Air Pressure Standards <90%, non-condensing 500 hpa to 1060 hpa Safety: Complies with UL , 1.ed., IEC , 2.ed.: + A1 + A2, 3.ed. + A1, CAN/CSA-22.2 No (2008), IEC 62471, 1.ed., IEC , 2.ed. EMC: IEC , 3.ed. Otometrics - ICS Impulse USB 171

172 15 Technical Specifications 15.2 Accessories Accessories Manuals/Videos Vision Denied Solution Quick Guide English Monocular Video Frenzel Quick Guide English vhit Quick Guide English Oculomotor Quick Guide English Positional Quick Guide English Monocular Video Frenzel Training Video DVD Oculomotor Training Video DVD vhit Training Video DVD Positional Training Video DVD xx xx xx xx xx Software OTOsuite Vestibular Goggles Face cushion 120/pkg Strap assembly Optical cleaning cloth ***Qty min 3*** Fixation dot (2 sheets/pkg) Vision Denied Solution (200 sets/pkg) Remote Control Clip Synchronized Room Video Microsoft Life Cam USB Camera Cables Cable clip Case/Mount Carrying case Wall mount Otometrics - ICS Impulse USB

173 15 Technical Specifications 15.3 Guidance and manufacturer s declaration tables ICS Impulse USB is part of a medical electrical system and is thus subject to special safety precautions. For this reason, the installation and operating instructions provided in this document should be followed closely. Portable and mobile high-frequency communication devices, such as mobile phones, may interfere with the functioning of ICS Impulse USB. Guidanceand manufacturer's declaration - electromagnetic emissions forallequipment and systems ICSImpulse USBis intended foruse inthe electromagnetic environmentspecified below. The user ofics Impulse USBshould ensure that itis used in such anenvironment. Emissions test Compliance Electromagneticenvironment - guidance RF emissions CISPR 11 RF emissions CISPR 11 Harmonic emissions IEC Voltage fluctuations/flicker emissions IEC Group 1 Class A Class A Complies ICS Impulse USB uses RF energy only for its internal function. Therefore, its RF emissions are very low and are not likely to cause any interference in nearby electronic equipment. ICS Impulse USB is suitable for use in all establishments other than domestic and those directly connected to the public low-voltage power supply network that supplies buildings used for domestic purposes. Immunity - All Equipment and Systems The ICS Impulse USB System was not tested for immunity to electromagnetic disturbances. Otometrics - ICS Impulse USB 173

174 App. 1 Calibration algorithm App. 1 Calibration algorithm During calibration the system completes the steps described here: 1. Turns on the left laser. 2. Grabs data every 500 ms. Continues until 3 values in a row, within 2 pixels of each other, are found. (Average of 3 values referred to as L1.) 3. Turns on the right laser. 4. Grabs data every 500 ms. Continues until 3 values in a row, within 2 pixels of each other, are found. (Average of 3 values is referred to as R1). 5. Repeats steps 1-4 to get L2 and R2. 6. Compares L1 and L2. If these values differ by more than 2 pixels, restarts at step Compares R1 and R2. If these values differ by more than 2 pixels, restarts at step Compares the distance between L1 and R1. If not within pixels, restarts at step Otometrics - ICS Impulse USB

175 App. 2 Head Impulse Collection and Analysis algorithms App. 2 Head Impulse Collection and Analysis algorithms Collection and Analysis algorithms Both algorithms look at the head and eye velocities for each head impulse. all 250 samples to determine if a head impulse should be rejected by comparing the data to the data of a proper head impulse (as defined by thousands of head impulses collected during research by our collaborators in Australia). The impulse is rejected if either head or eye data are outside of these conditions: Head movement: The trace of the head movement must have a shape similar to the training curve. Eye movement: The eye movement must be within a particular boundary which is comparable to how the eye should move during a proper head impulse. Analysis algorithm only Once an impulse has been accepted, prior to displaying the data in the 2D/3D Analysis windows, samples are eliminated at the start and end of the head to reduce the count to 175 samples. Analyzes the head data to detect the peak velocity of the head impulse. (Peak velocity is used in the gain calculation). In rare instances the analysis algorithm rejects a head impulse that is accepted by the collection algorithm. For example, if the eye velocity does not change within 10 samples, the algorithm assumes the pupil is at the edge of the ROI box and the pupil cannot be tracked. if the gain is more than +/- 2 SD from the mean. Rejections by the analysis algorithm can be avoided by properly setting up the test and performing a proper head impulse. Otometrics - ICS Impulse USB 175

176 App. 3 Understanding raw data files App. 3 Understanding raw data files Follow these instructions to create a file that has data organized in tabular form: 1. In the Export window select XML Files & ASCII Raw Data and export the patient. 2. Change the extension of the txt file from txt to csv to convert the exported file to a *.csv file (comma-separated values file). 3. Open the file and delete the first row of header information. The format of the file is specific to the test type: Eye Position Tests (Gaze, Skew Deviation, Positional: Dynamic and Repositioning) Column A Time Column B Eye position horizontal right (degrees that pupil has moved from center) Column C Eye position vertical right (degrees that pupil has moved from center) Column D Head position W (quaternion data) Column E Head position X (quaternion data) Column F - Head position Y (quaternion data) Column G - Head position Z (quaternion data) Column H Absolute Eye Position X (pupil center in pixel) Column I Absolute Eye Position Y (pupil center in pixel) VOR Tests (VVOR & VORS) Column A Time Column B VOR Head (velocity in degrees/second for horizontal test it is the lateral head movement and for the vertical test it is the vertical head movement ) Column C VOR Eye (velocity in degrees/second for horizontal test it is the horizontal eye movement for vertical it is the vertical eye movement) Column D Head position W (quaternion data) Column E Head position X (quaternion data) Column F - Head position Y (quaternion data) Column G - Head position Z (quaternion data) Column H Absolute Eye Position X (pupil center in pixel) Column I Absolute Eye Position Y (pupil center in pixel) 176 Otometrics - ICS Impulse USB

177 App. 3 Understanding raw data files Head Impulse (Lateral/LARP/RALP) Column A Time Column B Head: RALP gyro data (degrees per second) Column C Head: LARP gyro data (degrees per second) Column D Head: Lateral gyro data (degrees per second) Column E Eye: horizontal velocity (degrees per second) Column F - Eye: vertical velocity (degrees per second) Otometrics - ICS Impulse USB 177

178 App. 4 Using raw data to calculate latency App. 4 Using raw data to calculate latency Follow these instructions to create a file that has data organized in tabular form: 1. In the Export window select XML Files & ASCII Raw Data and export the patient. 2. Change the extension of the txt file from txt to csv to convert the exported file to a *.csv file (comma-separated values file). 3. Open the file and delete the first row of header information. The resulting file has these 6 columns. Column A Time Column B Head: RALP gyro data (degrees per second) Column C Head: LARP gyro data (degrees per second) Column D Head: Lateral gyro data (degrees per second) Column E Eye: horizontal velocity (degrees per second) Column F - Eye: vertical velocity (degrees per second) 178 Otometrics - ICS Impulse USB

179 App. 4 Using raw data to calculate latency 4. Insert a new column (in this example the new column is B). 5. In the first row of the new column enter zero 0 6. In the second row of the new column enter this formula =(A2-A1)/10000+B1 7. Select cell B2, copy the formula, and paste it into the remaining B cells. Column B now represents the time in milliseconds To calculate the latency, create a scatter plot of time (B column) on the x axis and for a lateral impulse either the lateral gyro data or eye horizontal velocity on the y axis. for a RALP impulse either the RALP gyro data or eye vertical velocity on the y axis for a LARP impulse either the LARP gyro data or eye vertical velocity on the y axis Otometrics - ICS Impulse USB 179