Neuro-ophthalmology Illustrated 16 – Nystagmus and Other Ocular Oscillations 3

Questions:
25. What is oculopalatal myoclonus?
26. What is oculomasticatory myorhythmia?
27. What is convergence retraction nystagmus?
28. What is superior oblique myokymia?
29. What is ocular bobbing?
30. What are saccadic intrusions?
31. What is ocular flutter?
32. What is opsoclonus?
33. What are the causes of ocular flutter and opsoclonus?
34. What is ocular dysmetria?
35. What is voluntary nystagmus?
36. What disease must be considered when a patient has confusion, ataxia, ophthalmoplegia (any pattern) and nystagmus?

Neuro-ophthalmology Illustrated Chapter 16 – Nystagmus and Other Ocular Oscillations 2

Questions:
13. What diagnosis is most likely when a patient has acquired nystagmus with positional vertigo?
14. What is the most important goal in the evaluation of central nystagmus?
15. Which patterns of jerk nystagmus have localizing value?
16. Which patterns of pendular nystagmus have localizing value?
17. What is downbeat nystagmus?
18. What is upbeat nystagmus?
19. What is periodic alternating nystagmus?
20. What is rebound nystagmus?
21. What is Brun nystagmus?
22. What is dissociated jerk nystagmus?
23. What is acquired pendular nystagmus?
24. What is seesaw nystagmus?

Recommended Reading – Abnormal Facial & Ocular Movement Videos

Recommended Reading – Abnormal Facial & Ocular Movement Videos

Short videos of abnormal facial and ocular movement seen in Dr. C.N. Chua’s clinic.

Ophthalmology Videos page 1 http://www.mrcophth.com/vidoes.html

Ophthalmology Videos page 2 http://www.mrcophth.com/videos2.html

From: Success in MRCOphth by Dr. C.N. Chua http://www.mrcophth.com/chua1.html

Neuro-ophthalmology questions of the week: NOI16-Nystagmus and Other Ocular Oscillations 4 – Other Nystagmoid Eye Movements

Questions:
24. What are the characteristics and the lesion location for convergence-retraction nystagmus?
25.  What are the characteristics, concerns, and treatment for superior oblique myokymia?
26. What are the characteristics, concerns, and the lesion location for ocular bobbing?
27. What are the characteristics of saccadic intrusions?
28. What are the characteristics and concerns for ocular flutter?
29. What are the characteristics and concerns for opsoclonus?
30. What are the characteristics and concerns for square-wave jerks and macrosquare-wave jerks?
31. What are the characteristics, concerns, and lesion location for ocular dysmetria?
32. What are the characteristics of voluntary nystagmus?
33. What are the characteristics, concerns and lesion location for internuclear ophthalmoplegia?

Recommended Reading – Treatment of Nystagmus and Saccadic Oscillations

Recommended Reading – Treatment of Nystagmus and Saccadic Oscillations

Treatment of Nystagmus and Saccadic Oscillations
Matthew J. Thurtell, and John J. Brinkley/ University of Iowa. EyeRounds.org. 2013
http://webeye.ophth.uiowa.edu/eyeforum/tutorials/Nystagmus/

Introduction
Nystagmus is often encountered in ophthalmology practice, having a prevalence of about 24 per 10,000 in the general population.[1] Unlike physiologic nystagmus, where the slow phases of nystagmus minimize retinal image slip, the slow phases of pathologic nystagmus cause retinal image slip. Retinal image slip of greater than 5 degrees per second produces a decline in visual acuity, partly because the image of the object of interest no longer lies on the fovea, and illusory motion of the visual environment known as oscillopsia.[2,3] Saccadic intrusions and oscillations can also cause visual symptoms, such as difficulty reading, since they take the eye off target so that the image of the object of interest no longer lies on the fovea.[2]

Goals of Treatment
The goal of treatment is to reduce visual symptoms (e.g., blurred vision, oscillopsia) by reducing the speed of nystagmus slow phases or by suppressing saccadic oscillations. Treatments that stop the eyes from moving altogether (e.g., botulinum toxin injections into the extraocular muscles) are not ideal, because they cause oscillopsia during head movements (due to loss of the vestibulo-ocular reflex) and diplopia (due to loss of vergence eye movements).[2] Thus, treatments that suppress the abnormal eye movements without affecting normal eye movements are preferred. Note that some types of nystagmus (e.g., gaze-evoked) and saccadic intrusions (e.g., square-wave jerks) do not usually give visual symptoms and, thus, do not require specific treatment.

General Approaches to Treatment
Treatments for nystagmus that have been proposed include medical, optical, surgical, and other miscellaneous treatments (Table 1); few of these have been evaluated in prospective masked clinical trials.[2,4] Likewise, a variety of treatments for saccadic oscillations have been proposed; few have been evaluated in prospective masked clinical trials.[2] Most treatments aim to suppress the abnormal eye movements without affecting normal eye movements, whereas others aim to negate the visual consequences of the abnormal eye movements. Choice of treatment depends on the type of nystagmus or saccadic oscillation and its characteristics. While some patients will derive benefit from one treatment approach, others require a combination of treatments.[2,4]

Full Article http://webeye.ophth.uiowa.edu/eyeforum/tutorials/Nystagmus/

 

Recommended Reading – Nystagmus Videos – Neuro-Ophthalmology Virtual Education Library

Recommended Reading – Nystagmus Videos – Neuro-Ophthalmology Virtual Education Library

List of related Videos from the Novel Moran Eye Center – Neuro-Ophthalmology Virtual Education Library

Novel Moran Eye Center – Neuro-Ophthalmology Virtual Education Library

https://collections.lib.utah.edu/search?facet_setname_s=ehsl_novel_jmec

Neuro-ophthalmology questions of the week: NOI16-Nystagmus and Other Ocular Oscillations 3 – Acquired Nystagmus

Questions:
Acquired Nystagmus
9. What are the characteristics, concerns, lesion location, and treatment for gaze-evoked nystagmus?
10.  What are the characteristics, concerns, lesion location, and treatment for nystagmus with positional vertigo?
11. What are the characteristics, concerns, lesion location, and treatment for downbeat nystagmus?
12. What are the characteristics, concerns, lesion location, and treatment for upbeat nystagmus?
13. What are the characteristics, concerns, lesion location, and treatment for periodic alternating nystagmus?
14. What are the characteristics, concerns, and lesion location for rebound nystagmus?
15.  What are the characteristics and lesion location Brun nystagmus?
16. What are the characteristics, concerns, and treatment for dissociated jerk nystagmus?
17. What are the characteristics, concerns, lesion location, and treatment for acquired pendular nystagmus?
18. What are the characteristics, concerns, lesion location, and treatment for seesaw nystagmus?
19. What are the characteristics, lesion location, and treatment for oculopalatal myoclonus?
20. What are the characteristics, concerns, lesion location, and treatment for oculomasticatory myorhythmia?
21. What are the characteristics, concerns, and treatment for Wernicke encephalopathy?
22. Which patterns of jerk nystagmus have localizing/diagnostic value?
23. Which patterns of pendular nystagmus have localizing/diagnostic value?

Recommended Reading – The clinical evaluation of infantile nystagmus: What to do first and why

Recommended Reading – The clinical evaluation of infantile nystagmus: What to do first and why

The clinical evaluation of infantile nystagmus: What to do first and why.
Morgan Bertsch, Michael Floyd, Taylor Keohea, Wanda Pfeifer, and Arlene V. Dracka Ophthalmic Genet. 2017 ; 38(1): 22–33.
Department of Ophthalmology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA

Abstract Introduction—Infantile nystagmus has many causes, some life threating. We determined the most common diagnoses in order to develop a testing algorithm.

Methods—Retrospective chart review. Exclusion criteria were no nystagmus, acquired after 6 months, or lack of examination. Data collected: pediatric eye examination findings, ancillary testing, order of testing, referral, and final diagnoses. Final diagnosis was defined as meeting published clinical criteria and/or confirmed by diagnostic testing. Patients with a diagnosis not meeting the definition were “unknown.” Patients with incomplete testing were “incomplete.” Patients with multiple plausible etiologies were “multifactorial.” Patients with negative complete workup were “motor.”

Results—284 charts were identified; 202 met inclusion criteria. The 3 most common causes were Albinism(19%), Leber Congenital Amaurosis(LCA)(14%) and Non-LCA retinal dystrophy (13%). Anatomic retinal disorders comprised 10%, motor another 10%. The most common first test was MRI (74/202) with a diagnostic yield of 16%. For 28 MRI-first patients, nystagmus alone was the indication; for 46 MRI-first patients other neurologic signs were present. 0/28 nystagmus-only patients had a diagnostic MRI while 14/46 (30%) with neurologic signs did. Yield of ERG as first test was 56%, OCT 55%, and molecular genetic testing 47%. 90% of patients had an etiology identified.

Conclusion—The most common causes of infantile nystagmus were retinal disorders (56%), however, the most common first test was brain MRI. For patients without other neurologic stigmata complete pediatric eye examination, ERG, OCT and molecular genetic testing had a higher yield than MRI scan. If MRI is not diagnostic, a complete ophthalmologic workup should be pursued.

Full Article https://drive.google.com/open?id=1h76ziIrxB6TpINMsPF1mcsWvvAvVkaj3

 

NOI16-Nystagmus and Other Ocular Oscillations 2 – Infantile Nystagmus

Questions:
Infantile (congenital) Nystagmus
5. What are the characteristics, associated conditions, concerns, and treatment for infantile nystagmus?

Other Types of Infantile Nystagmus
6. What are the characteristics and associated conditions for latent nystagmus?
7. What are the characteristics, associated conditions, concerns, lesion location and treatment for spasmus nutans?
8. What are the characteristics, and lesion location for infantile monocular pendular nystagmus?

https://lh4.googleusercontent.com/Gt4dXacAnmGJwfgR9EIJQVdqsG39U_FLEbrM7T1e_YCH8Raza2n7WAW4vHFELSC4gsZ2sCgoBYrlcftn1TA4jji2un1nBpYJzznscv4y6lnJvxBvuKPRD8WBV_2y4u3GDM4hvSmj

Heimann-Bielschowsky phenomenon

Recommended Reading
Teaching Video NeuroImages: Heimann-Bielschowsky phenomenon
A harmless monocular nystagmus

Article:
Heimann-Bielschowsky phenomenon (HBP) is a rare form of dissociated nystagmus.1 A 38-year-old man complained of poor vision in his right eye for 6 years. Right visual acuity was 20/200 due to traumatic aphakia (cataract extraction without intraocular lens) and 20/20 in the left eye. An asymptomatic coarse, low frequency, pendular, vertical nystagmus was manifest in the right eye only (video, http://links.lww.com/WNL/A177). HBP is an asymptomatic monocular slow, pendular, mostly vertical nystagmus, which can develop years after uniocular severe visual loss.1 The pathogenesis of HBP is debated, but vertical fusion disruption due to monocular visual loss is hypothesized.2 Recognizing HBP should prevent unnecessary investigations or treatments.

Teaching slides: http://links.lww.com/WNL/A178

Video: http://links.lww.com/WNL/A177

Neurology
February 20, 2018; 90 (8)
RESIDENT & FELLOW SECTION

References

  1. Yee RD, Jelks GW, Baloh RW, Honrubia V. Uniocular nystagmus in monocular visual loss. Ophthalmology 1979;86:511–522.
  2. Leigh RJ, Thurston SE, Tomsak RL, Grossman GE, Lanska DJ. Effect of monocular visual loss upon stability of gaze. Invest Ophthalmol Vis Sci 1989;30:288–292.