Nystagmus

Nystagmus is defined as involuntary, rhythmic, biphasic oscillation of eyes. It is characterized as horizontal, vertical, rotary, or a combination; fast or slow; symmetric or asymmetric; and pendular (equal speed in either direction) or jerk (slow in one direction followed by fast in the opposite direction). By convention, nystagmus is named in the direction of the fast phase. Usually results from a defect in the slow eye movement system (visual fixation, vestibular system, smooth pursuit, vergence, optokinetic, and neural integrator pathways).

Differential Diagnosis

• Vestibular
  –Peripheral (horizontal rotary nystagmus, slow phase toward hypoactive side, latency, fatigability, and accompanied by vertigo, tinnitus, or deafness): Etiologies include labyrinthitis, vestibular neuronitis, Ménie're's disease, migraine, BPV
  –Central (asymmetric, rotary nystagmus that changes direction in different gazes, no latency, not fatigable): Etiologies include lesions of cerebellum, pons, or cerebellopontine angle
  –Horizontal
• Gaze-evoked
  –Physiologic: Fixing on objects with eyes when head is turned (e.g., ballerinas)
  –Pathologic (asymmetric): Etiologies include toxic-metabolic lesions, cerebellar or pontine lesions
• Dissociated (different nystagmus between eyes): Etiologies include internuclear ophthalmoplegia of multiple sclerosis or cerebral disease
• Periodic alternating nystagmus (cervicomedullary junction)
• Downbeat (cervicomedullary junction, characteristic of syringobulbia)
• Upbeat (brainstem or cerebellum when present in primary gaze; drug effect if only present in upgaze)
• Drug-induced (e.g., anticonvulsants, sedatives, alcohol)
• Monocular visual loss (ipsilateral slow vertical oscillation)
• Head nodding, head turn (due to motor or sensory deficits)
  –Latent nystagmus (occurs only when one eye is viewing, and is always associated with strabismus)
  –Nystagmus blockage syndrome (convergence, esotropia, and head turn)
  –Spasmus nutans: Onset 4–14 months, resolves by age 5; head nodding, torticollis, see-saw

Workup and Diagnosis

• History and physical examination
  –Note age of onset, associated symptoms (e.g., oscillopsia, decreased vision, nausea/vomiting, vertigo, hearing loss, tinnitus, diplopia, dysarthria, facial numbness, dysphagia), medications, and drug use
  –Complete ocular exam: Eye movements in primary gaze and all positions of gaze; iris transillumination (albinism), dilated fundus exam, careful refraction, vestibulo-ocular reflex
  –Dix-Hallpike maneuver (for positional vertigo, peripheral versus central)
  –Caloric stimulation
  –Complete neurologic examination
  –Nystagmus is asymptomatic, unless acquired after age 8, at which time the patient may have oscillopsia (a sense that the surroundings are oscillating)
• Consider drug, toxin, and dietary screen of urine/serum
• Consider MRI of brain
• Consider visual field exam
• Consider neurology and/or ophthalmology consultation
  –Eye movement recording
  –Electronystagmogram
  –Visual evoked response
  –Electroretinography

Treatment

• Treat the underlying etiology if possible
• Remove offending medications/toxins if possible
• Medications to treat the nystagmus (e.g., meclizine for BPV) have varying success
• BPV: Otolith repositioning maneuvers (Epley's, Semont's)
• Botulinum toxin injection to the appropriate extraocular muscles may be used for severe disabling nystagmus
• Congenital nystagmus: Maximize vision by refractive lenses, treat amblyopia (“lazy eye”) if indicated, prism, and/or eye muscle surgery
• Vestibular: Vestibular suppressant (meclizine, diazepam), vestibular adaptation exercises
• Baclofen may be useful in periodic alternating nystagmus and some congenital nystagmus
• Clonazepam for downbeat nystagmus

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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