Acquired nystamus

History
Important aspects of the history include the following:

Age of onset of the nystagmus, whether it is constant or intermittent, the

presence of any aggravating or alleviating factors (eg, head position)

Presence or absence of vertigo, oscillopsia (an illusory motion of the seen

world),[10] and sensation of disequilibration suggest a lesion of the
vestibular system.

Deafness or tinnitus is present with peripheral lesions of the vestibular

system.

Presence of diplopia, particularly in certain positions of gaze: Patients with

INO may report diplopia only on lateral gaze or intermittent blurring of
vision.

Ask questions regarding the presence of any associated symptoms, such

as symptoms related to demyelinating disease (eg, a history of loss of
vision, eye pain, or numbness or weakness of the extremities), symptoms
related to cerebrovascular accident (eg, hemiplegia).

Physical
A complete neuro-ophthalmic examination is imperative in patients with
nystagmus. Aside from a complete ophthalmic examination, including visual
acuity, measurement and reactivity of the pupils to light and accommodation,
measurement of intraocular pressure, testing the function of extraocular
muscles, and anterior and dilated posterior segment examination, other
important aspects of the examination include the following:

Observing the nystagmus with regard to type (eg, horizontal, vertical),

frequency, amplitude, direction, and conjugate/disconjugate is important.
Pure vertical, pure horizontal, or pure rotary nystagmus almost always
represents central vestibular dysfunction.

Note whether the character of the nystagmus changes in certain directions

of gaze.

Nystagmus due to vestibular disease increases in intensity when the

eyes are turned in the direction of the saccade (fast phase), ie,
Alexander law.

A horizontal nystagmus due to peripheral vestibular imbalance

remains horizontal on upward and downward gaze.

Note the presence or absence of head nodding or torticollis (spasmus

nutans).

Note whether the nystagmus dampens with fixation. Fixation inhibits

nystagmus and vertigo due to peripheral lesions of the vestibular system.

Optokinetic nystagmus (OKN) drum: The optokinetic reflex allows us to

follow objects in motion when the head remains stationary (eg, observing
individual telephone poles on the side of the road as one travels by them
in a car). The reflex develops at about age 6 months. The normal eye
movements that one observes depend upon the orientation of the drum in
front of the patient. If the drum is held in front of the patient with the bars
directed vertically and is spun to the left (the patient's right), one would
observe a slow pursuit movement of the eyes to the patient's right as a
moving bar is followed, then a quick saccade to the patient's left as the
patient searches for the next moving bar to fixate on and again follows
that bar with a slow pursuit movement to the patient's right.
o

This reflex is abnormal in patients with congenital nystagmus. One

may observe a paradoxical reversal of the optokinetic nystagmus
response.

Patients with horizontal nystagmus with unilateral hemispheric

lesions, especially parietal or parietal-occipital lesions, show
impaired optokinetic nystagmus when the drum is rotated toward
the side of the lesion.

The OKN drum may be used as an estimate of visual acuity. The

striped drum is equivalent to a vision of counting fingers when held
at a distance of 3-5 feet from the patient. The further the drum is
from the patient, the better the visual acuity must be to respond
normally to the moving drum.

Confrontational visual field testing may reveal gross field defects that may
help determine the presence and/or location of an intracranial lesion.

For Romberg testing have the patient stand with eyes closed and feet
together. If a defect in the vestibular system is present, the patient tends
to fall toward the side of the lesion.

Oculocephalic reflex (doll's head phenomenon)

o

The oculocephalic reflex develops within the first week of life and
essentially represents a vestibulo-ocular reflex normally suppressed
in a conscious individual that attempts to turn the head to fixate on
an object.

This test consists of the rapid rotation of the patient's head in a

horizontal or vertical direction. With intact vestibular nuclei and
medial longitudinal fasciculi, the eyes move conjugately in the
opposite direction of the head turn. Alternatively, the test may be
performed by having the patient extend the arm out in front of the
body and fixate on the outstretched thumb. Patients should be

instructed to rotate their torso back and forth about their

longitudinal axis such that the thumb remains in front of the body at
all times.

Patients with the ability to suppress the oculocephalic reflex should

be able to maintain fixation on their thumb while rotating. An
abnormal test result would show the patient continuously losing
fixation of the thumb.

Inability to suppress the oculocephalic reflex is common in patients

with vestibular imbalance.

Caloric testing
o

Instilling cold or warm water into the external auditory canal can
reproduce the same movement of endolymph in the semicircular
canals produced by rotations of the head. Instillation of water into
the external auditory canal causes endolymph convection currents
that in turn induce nystagmus.

While sitting erect, the patient tilts the head back 60. While in
supine, the patient elevates the head 30; this brings the horizontal
semicircular canals into the vertical plane.

The external auditory canal is irrigated with cold or hot water. Cold
water instilled into the right ear causes the endolymph in the right
semicircular canal to cool and sink. This movement of endolymph is
the same movement induced by a rotation of the head to the left,
inducing a horizontal nystagmus directed to the left (ie, to the
opposite side the water was placed). Warm water in the same ear
produces the opposite effect (ie, a horizontal nystagmus directed to
the right or toward the same side the water was placed); ie, coldopposite, warm-same (COWS).

Note whether the character of the nystagmus changes with otolithic

stimulation. Failure to respond to otolithic stimuli implies peripheral
vestibular disease.

Causes

Seesaw nystagmus

Rostral midbrain lesions

Parasellar lesions (eg, pituitary tumors)

Visual loss secondary to retinitis pigmentosa

Downbeat nystagmus

Lesions of the vestibulocerebellum and underlying medulla,

including the following:

Arnold-Chiari malformation

Demyelination (eg, multiple sclerosis)[14]

Microvascular disease with vertebrobasilar insufficiency

Brain stem encephalitis

Tumors at the foramen magnum (eg, meningioma, cerebellar

hemangioma)

Trauma

Drugs (eg, alcohol, lithium, antiseizure medications)

Nutritional (eg, Wernicke encephalopathy, parenteral feeding,

magnesium deficiency)

Heat stroke

Approximately 50% have no identifiable cause.

Upbeat nystagmus

Medullary lesions, including perihypoglossal nuclei, the adjacent

medial vestibular nucleus, and the nucleus intercalatus (structures
important in gaze holding)

Lesions of the anterior vermis of the cerebellum

Benign paroxysmal positional vertigo

Periodic alternating nystagmus

Arnold-Chiari malformation

Demyelinating disease

Spinocerebellar degeneration

Lesions of the vestibular nuclei

Head trauma

Encephalitis

Syphilis

Posterior fossa tumors

Binocular visual deprivation (eg, ocular media opacities)

Pendular nystagmus

Demyelinating disease

Monocular or binocular visual deprivation

Oculopalatal myoclonus

Internuclear ophthalmoplegia

Brain stem or cerebellar dysfunction

Spasmus nutans

Usually occurs in otherwise healthy children

Chiasmal, suprachiasmal, or third ventricle gliomas may cause a

condition that mimics spasmus nutans.

Torsional - Lateral medullary syndrome (Wallenberg syndrome)

Abducting nystagmus of internuclear ophthalmoplegia

Demyelinating disease

Brain stem stroke

Gaze evoked

Drugs - Anticonvulsants (eg, phenobarbital, phenytoin,

carbamazepine) at therapeutic dosages

Alcohol

Congenital nystagmus
History
There is often a known family history of this disorder. The pattern of heredity is
usually sex-linked, with dominant being more common.
Establishing the precise age of onset is helpful in differentiating between sensory
deficit and idiopathic infantile forms. Spasmus nutans rarely is seen prior to age
4 months. Onset prior to age 2 months, particularly in the setting of gazeassociated variable intensity and torticollis, strongly suggests idiopathic infantile
nystagmus.
Patients with infantile nystagmus due to albinism may have a positive family
history and often appear photosensitive. A history of infantile strabismus
increases the likelihood of latent or manifest latent nystagmus.
A history of abnormal head movements (bobbing or nodding) or torticollis raises
the possibility of spasmus nutans.

CNS disease can produce many other forms of nystagmus and always must be
considered. A history of failure to thrive or other evidence of neurologic
dysfunction should prompt immediate investigation.
Older children and adults with a history of infantile nystagmus typically deny
oscillopsia but frequently may have signs and symptoms of accommodative
dysfunction. These signs and symptoms include asthenopia, headaches,
avoidance of near tasks, tearing, and blurry vision.
Both idiopathic infantile nystagmus and many forms of sensory deficit
nystagmus have a familial pattern. X-linked, autosomal dominant, and autosomal
recessive modes of inheritance have been reported.
Physical
Both sensory deficit nystagmus and idiopathic infantile nystagmus are almost
always bilateral, symmetric, and conjugate. [2]
Eye movements usually are horizontal and remain so during vertical gaze
(uniplanar) rather than changing to a gaze-evoked vertical nystagmus. The
nystagmus disappears during sleep.
The nystagmus movements may be pendular or jerk in nature. The nystagmus
may be intermittent or continuous. The congenital nystagmus patient may have
good vision or poor vision. There is no oscillopsia. There may be an inversion of
the optokinetic reflex.
Nystagmus intensity (a product of the frequency and amplitude) often increases
with fixation effort, attention, or anxiety, and diminishes with convergence.
Various waveforms have been described. Both pendular and jerk types have
been documented to occur in idiopathic infantile and sensory deficit nystagmus.
Nystagmus associated with albinism has characteristics similar to idiopathic
infantile nystagmus. Latent and manifest latent nystagmus always are jerk-type
with the fast phase in the direction of the fixing eye and decreasing velocity of
the slow phase; the nystagmus is larger in the amblyopic or nonfixing eye, and
amplitude decreases in adduction. Spasmus nutans classically is a triad of
nystagmus, head nodding, and torticollis. The nystagmus is disconjugate, high
frequency, small amplitude, pendular, and intermittent. It is suppressed with
head nodding. A head tilt often is present. Spasmus nutans often disappears
after a few years.
The hallmark of idiopathic infantile nystagmus is a gaze-dependent, variable
intensity resulting in a "null zone" where nystagmus is least marked and visual
acuity is maximized. This often corresponds to adoption of an anomalous head
posture and is frequently the stated reason for referral.
Causes
Idiopathic infantile nystagmus is believed to be due to a primary abnormality in
oculomotor control. Increasing evidence suggests a genetic mechanism with one

gene mapped to the X chromosome and another gene mapped to band 6p12.
Hackett et al have found evidence that mutations in the calcium/calmodulindependent serine protein kinase (CASK) gene are frequently associated with
congenital nystagmus and X-linked mental retardation. [3]
Many ocular disorders have been associated with sensory deficit nystagmus. This
is not meant to be an exhaustive listing. The variety of sensory causes suggests
that the underlying cause is a failure of sensorimotor integration due to reduced
vision and/or contrast sensitivity. See the following:

Early (usually bilateral) visual deprivation (eg), congenital cataracts,

severe glaucoma, Peters anomaly[4]

Foveal hypoplasia (eg, aniridia, albinism [nystagmus associated with

albinism has characteristics similar to idiopathic infantile nystagmus])

Retinal disease (eg, Leber congenital amaurosis, achromatopsia, macular

toxoplasmosis [especially if bilateral])

Retinal detachment (eg, severe retinopathy of prematurity, posterior

persistent hyperplastic primary vitreous, familial exudative
vitreoretinopathy)

Optic nerve abnormalities (eg, hypoplasia, coloboma, atrophy)

Cortical visual impairment from perinatal insult or structural CNS

abnormality

Nystagmus associated with albinism is the result of multifactorial visual

impairment. Anatomical findings include abnormal ocular pigmentation, foveal
hypoplasia, abnormally increased chiasmal decussation, and high cylindrical
refractive errors. Several subtypes have been described. Most are autosomal
recessive, but all modes of inheritance have been described.
Latent nystagmus is a conjugate, jerk nystagmus with the fast phase toward the
side of the fixing eye. It is often seen in patients with congenital esotropia and
following surgery for infantile esotropia, probably resulting from subnormal
binocular interaction. Latent nystagmus can coexist with manifest nystagmus (in
which case the nystagmus amplitude increases with occlusion). Latent
nystagmus is a jerk nystagmus with the fast phase toward the side of the fixing
eye. It often is seen following surgery for infantile esotropia and probably results
from subnormal binocular interaction. Visual acuity measurement should be
performed using the polarized vectograph or blurring one eye with a high plus
lens to avoid iatrogenic reduction of acuity with occlusion. So-called manifest
latent nystagmus can occur if monocular visual loss occurs in this setting.
The cause of spasmus nutans is unknown. Some studies have found an
association with children from lower socioeconomic status, as well as coexisting
strabismus and refractive error. Chiasmal glioma can present with an identical

appearing nystagmus prior to affecting the anterior visual pathway. It may be

more common in African Americans and in Latinos
TREATMENTS- hertle
There are a number of signs and symptoms due to nystagmus that are amenable
to treatment. The fi rst and most obvious is decreased vision (central visual
acuity, gaze- angle acuity, near acuity). Correction of signifi cant refractive
errors in children with nystagmus is the single most powerful therapeutic
intervention for improving vision and visual function in these patients. Refractive
etiologies of decreased vision include either one or a combination of conditions
e.g., myopia, hyperopia, astigmatism, and anisometropia. These refractive
conditions can contribute signifi cantly to already impaired vision in patients with
other organic etiologies of decreased visione.g., amblyopia, optic nerve and /
or retinal disease, oscillopsia, and the oscillation itself. The second

Optical Treatments13
Convergence prisms provide one optical approach for patients with congenital or acquired
nystagmus whose nystagmus dampens when they view a near target (242,523); a useful
starting point is 7.00-diopter base-out prisms combined with -1.00-diopter spheres to
compensate for accommodation (although the spherical correction may not be needed in
presbyopic individuals). In some patients with congenital nystagmus, the resultant
improvement of vision is sufficient for them to qualify for a driver's license. Patients whose
nystagmus is worse during near viewing may benefit from wearing base-in (divergence)
prisms (64).
Theoretically, it should be possible to use prisms to help patients whose nystagmus is reduced
or absent when the eyes are moved into a particular position in the orbit: the null region. For
patients with congenital nystagmus, there is usually some horizontal eye position in which the
nystagmus is minimized, whereas downbeat nystagmus may decrease or disappear in upgaze.
In practice, patients use head turns to bring their eyes to the optimum position, and only
rarely are prisms that produce a conjugate shift helpful.
A different approach to the treatment of nystagmus has been the use of an optical system that
stabilizes images on the retina (524). This system consists of a high-plus spectacle lens worn
in combination with a high-minus contact lens. The system is designed on the principle that
stabilization of images on the retina could be achieved if the power of the spectacle lens
focused the primary image close to the center of rotation of the eye. However, such images
are then defocused, and a contact lens is required to extend the clear image back onto the
retina. Since the contact lens moves with the eye, it does not negate the effect of retinal image
stabilization produced by the spectacle lens. With such a system, it is possible to achieve up
to about 90% stabilization of images upon the retina. There are several limitations to the
system, however. One is that it disables all eye movements (including the vestibulo-ocular
reflex and vergence) and thus is useful only when the patient is stationary and is viewing
monocularly. Another limitation is that with the highest-power components (contact lens of
-58.00 diopters and spectacle lens of +32diopters), the field of view is limited. Some patients
with ataxia or tremor (such as those with MS) have difficulty inserting the contact lens.
However, initial problems posed by rigid polymethyl methacrylate contact lenses can be
overcome by using gas-permeable, or even soft contact lenses (525). Most patients do not
need the highest power components for oscillopsia to be abolished, and vision to be

improved. We have found that in selected patients the device may prove useful for limited
periods of time, for example, if the patient wishes to watch a television program (526).
Contact lenses alone sometimes suppress congenital nystagmus (527). This effect is not from
the mass of the lenses but is probably mediated via trigeminal afferents (528); this issue is
discussed further below.
A more recent innovation has been to use an electronic circuit to distinguish between the
nystagmus oscillations and normal eye movements (529). This approach is most applicable in
patients with pendular nystagmus. Eye movements are measured using an infrared sensor
and, after filtering, fed to a phase-locked loop that generates a signal similar to the nystagmus
but is insensitive to other eye movements, such as saccades. This electronic signal is then
used to rotate Risley prisms, through which the patient views the environment. When the
Risley prisms rotate in synchrony with the patients nystagmus, they negate the visual effects
of the ocular oscillations. Improvement and miniaturization of a prototype device may
eventually lead to a spectacle-mounted device that selectively cancels out the visual effects of
pathological nystagmus (529,530).
The main therapy for latent nystagmus consists of measures to improve vision, particularly
patching for amblyopia in children (531).
Surgical Procedures for Nystagmus
Two surgical procedures may be effective for certain patients with congenital
nystagmus. One is the Anderson-Kestenbaum operation (538,539,540). This
procedure is designed to move the attachments of the extraocular muscles so
that the new central position of the eyes is at the null position. It is performed
after first making careful eye movement measurements of nystagmus intensity
with the eyes in various positions of gaze and determining the approximate null
position. The appropriate extraocular muscles are then weakened or
strengthened as necessary to achieve the required shift in the position of the null
(541,542,543). The Anderson-Kestenbaum procedure not only shifts and
broadens the null region, but also results in decreased nystagmus outside the
region. It is of uncertain value in the treatment of acquired forms of nystagmus.
The second procedure is an artificial divergence operation (544,545). It may be
helpful in patients with congenital nystagmus that dampens or is suppressed
during near viewing and who have stereopsis. Studies comparing these two
methods indicate that the artificial divergence operation generally
P.1165
results in a better visual outcome than the Anderson-Kestenbaum procedure
alone (543,545,546,547).
Several authors have recommended performing large recessions of all of the
horizontal rectus muscles for treatment of patients with congenital nystagmus
(548,549). Based on a long experience, Dell'Osso noted that any surgical
procedure that detached and reattached the extraocular muscles tended to
suppress congenital nystagmus. This led him to suggest that simply dissecting
the perimuscular fascia and then reattaching the muscles at the same site on the

globe might prove effective, especially in cases when convergence does not
dampen the nystagmus. Results of this procedure on a canine model for
congenital nystagmus supported this hypothesis (550). Reported lack of effect in
monkeys concerns latent nystagmus, not typical congenital nystagmus
(551,552). Preliminary results of a large, controlled clinical trial suggest that the
operation is effective in some patients (242,553).
How could such a procedure damp congenital nystagmus? Recent studies by
Bttner-Ennever and colleagues have indicated that the terminal portion of the
extraocular muscles, near their site of their attachment, contains multiplyinnervated muscle fibers (554). Using rabies toxin as an anatomic tracer, it has
been possible to show that a separate group of ocular motor neurons (distinct
from the classic oculomotor, trochlear, and abducens nuclei, and surrounding
each of them) innervates these multiply-innervated fibers.
Finally, it is known that ocular proprioceptors (the pallisade organs) lie at the
insertion site of the extraocular muscles (554). Thus, procedures similar to those
proposed by Dell'Osso may work by disrupting a proprioceptive feedback
pathway that normally sets the tone of the extraocular muscles.
There is also some evidence that the tendino-scleral junction may contain
neurovascular abnormalities in the eyes of patients with congenital nystagmus
(555). This suggestion, and the orbital revolution set in motion by the discovery
of pulleys for the extraocular muscles by Miller and Demer, promise the
development of new therapies for congenital nystagmus (556).
The role of surgery in the treatment of acquired nystagmus is not well
established, although individual patients may benefit from recession operations
(506,557). However, it is clear that suboccipital decompression improves
downbeat nystagmus in Chiari syndromes and also prevents progression of other
neurologic deficits (558,559,560).
As noted above, SOM that does not respond to treatment with medication may
respond to extraocular muscle surgery. The procedure used by most surgeons is
a superior oblique tenectomy combined with myectomy of the ipsilateral inferior
oblique muscle (414,415,417,422,561). However, Kosmorsky and colleagues
reported successful treatment of a patient with SOM by performing a nasal
transposition of the anterior portion of the affected superior oblique tendon,
thereby weakening cyclorotation (562).
Other Forms of Treatment
A variety of methods other than those described above have been used to treat
nystagmus, principally the congenital variety. Electrical stimulation or vibration
over the forehead may suppress congenital nystagmus (264). The mechanism of
vibration on eye movements is uncertain, since vibration over the mastoid in
patients who have lost vestibular function induces ocular torsion (563). However,
it is postulated that the suppressive effect on congenital nystagmus, as well as

suppression induced by wearing contact lenses (528), may be exerted via the
trigeminal system, which receives extraocular proprioception (264,554).
Acupuncture administered to the neck muscles may suppress congenital
nystagmus in some patients via a similar mechanism (564,565). Biofeedback has
also been reported to help some patients with congenital nystagmus (566,567).
The role of any of these treatments in clinical practice has yet to be
demonstrated.

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Walsh___Hoyt_s_Clinical_Neuro-Ophthalmology__6th_Edition2005 - pathogenesis