Gaze

• Function of the Gaze System

– Maintain visual fixation of an object on the
fovea of the eye during fixed, visual gaze
• Purpose of the Gaze Test
– Identify presence of spontaneous eye motion
during visual fixation
 Gaze Test
• Protocol:
– Gaze Center patient sitting
• At least 1 meter away
• Minimum 30 seconds
– Gaze Center patient sitting
• Vision denied (and fixation)
• 8-30 seconds
– Gaze right, Gaze Left, Gaze Up, Gaze Down all
with eyes open.
 Gaze Nystagmus
• Types of nystagmus that can be observed
during gaze testing
– 1. Direction changing nystagmus
• Right gaze – right beating
• Left gaze – left beating
• Upward gaze – up beating
• Points to brainstem or cerebellar lesion
 Gaze Nystagmus
• 2. Direction Fixed and Horizontal
– Always in one direction irrespective of direction
of gaze
– Indicates peripheral lesion
• 3. True rotatory gaze nystagmus
– Indicates brainstem lesion
• 4. Vertical gaze nystagmus
– Up-beating: brainstem
– Down-beating: cervico-medullary
 Gaze Nystagmus
• 5. Periodic
Alternating
– Changes
direction every
2-6 minutes
• Indicates
cerebellar,
brainstem or
midbrain lesion
• 6. Square wave
– Rule out
tense/nervous
Gaze Nystagmus -- Specifics
• Direction Fixed Horizontal
– If the ocular motor battery is normal
• 96% chance this is due to peripheral vestibular
system (end organ or nerve) pathology
• Nystagmus usually beats away from the weak ear
– Ie. Right beating suggests left ear weakness; left
beating suggests right ear weakness
• Nystagmus is stronger with eyes closed
• ACUTE unilateral peripheral lesions may show a
rotary component in addition to primarily horizontal
nystagmus
– Often can only see with with frenzels or infra-red closed
cover
Gaze Nystagmus -- Specifics
• Direction- Changing Horizontal
– Need to rule out:
• End point nystagmus
• CNS medications
• Horizontal canal BPPV
Gaze Nystagmus -- Specifics
• Vertical
Nystagmus
– Upbeating:
• Brainstem or
cerebellum
• NEVER Peripheral
• With eyes closed
only: unknown
clinical
significance
– Down beating: Arnold-Chiari Malformation
• Lesion in
cerebellum or www.members.shaw.ca/hilaryking/Chiari.JPG

cervico-medullary
Downbeat Nystagmus
Gaze Nystagmus -- Specifics
• Rotary
– Brainstem (vestibular nuclei)
– Seen in cerebellar disease also
– AS SEEN IN GAZE NOT BPPV
• Ocular Nystagmus
– Pendular with center gaze
– Never vertical
– Suppresses with convergence
– Has null point
– Present from early life
– Site of lesion--- unknown
 Gaze Nystagmus - Hints
• Central vs. Peripheral
– 1. Less likely central if noted in primary
position
– 2. Central origin gaze nystagmus will be equal
or greater with fixation compared to non-
fixation for Slow-component velocity
• Peripheral, slow-component velocity is significantly
reduced with fixation
– 3. Presence of rebound nystagmus (transient
nystagmus where the fast component is in the
direction of the last eye movement) following
return to primary position from lateral gaze
position where nystagmus present
• Much more likely to be brainstem or cerebellar
Analysis - Gaze
 Analysis - Gaze
• Percent Ends:
– A “%” of the
current test “step”
is discarded from
beginning and
end.
• Increase the % and
the green cursors
move together with
less data analyzed.
• Prime Threshold:
try not to adjust
– This gets rid of
small “flutter” in
the eye signal
– If you adjust it too