The Nystagmus Blockage Syndrome

Congenital Nystagmus, Manifest Latent Nystagmus, or Doth?
L F. Dell'Osso,* C. Ellenberger, Jr.,* L. A. Abel,* and J. T. Flynnf

We have carefully studied, by quantitative oculography, a patient with the nystagmus blockage syndrome
(NBS), and two patients with a similar disorder of eye movements that might be mistaken clinically
for NBS. Our recordings revealed two distinctly different abnormalities present in a single patient with
NBS. Our NBS patient exhibited congenital nystagmus (CN) waveforms when viewing at distance; the
CN did not damp with convergence on a near target. When the patient allowed one eye to become
esotropic, however, the nystagmus damped considerably and abruptly changed from CN to manifest
latent nystagmus (MLN). This peculiar transition from CN to MLN has not been described previously.
The appearance of MLN in a case with ongoing CN suggests that two different mechanisms may
underlie NBS, since the only other case documented with eye movement recordings showed no transition
to MLN. Because the diagnosis of NBS usually is made on evidence of clinical signs alone, it is probable
that these two types have been combined indiscriminately and presented as one syndrome. In addition,
our discovery of two mechanisms discernable only by quantitative recording suggests that NBS has
been diagnosed inappropriately in patients with clinically similar but oculographically different eye
signs. Further quantitative studies are required to fully define NBS and to determine if these are the
only two mechanisms found in this syndrome. Invest Ophthalmol Vis Sci 24:1580-1587, 1983

The nystagmus blockage (blockierungs, compen- associated with manifest latent nystagmus (MLN), are
sation) syndrome (NBS) denotes a particular type of mistaken for NBS; and (3) the diagnosis usually is
nystagmus that begins in early infancy (ie, congenital made by clinical observation rather than by accurate
nystagmus—CN) and is accompanied by esotropia. oculography. The patients most commonly misdi-
NBS is characterized by a reduction of the nystagmus agnosed as having NBS are those with MLN, esotropia,
when esotropia increases. As the viewing eye follows and Alexander's Law variation; they have been well-
a target moving laterally towards the primary position described and their ocular movements recorded.1 Al-
and then into abduction, the nystagmus increases and exander's Law variation is the nystagmus amplitude
the esotropia decreases. The name "nystagmus block- increase as the eyes are directed towards the fast phases
age syndrome" reflects the prevalent assumption that of the nystagmus.
patients block their nystagmus by adducting one eye. We describe the clinical and oculographic findings
The adducted eye may be the fixing eye (ie, accom- of three patients. One patient had NBS, and two had
panied by a head turn) or it may be the non-fixing a combination of esotropia and nystagmus that clin-
eye (ie, when a patient views an object in primary ically resembled NBS, but, by both careful clinical and
position with his head straight). In both cases, the nys- oculographic measurements, was not. Using quanti-
tagmus is reduced when the esotropia occurs. tative oculography with special attention to the relative
The diagnosis of NBS is difficult to make because positions of each eye and the target, we can elucidate
(1) precise and uniform diagnostic criteria are lacking; at least two different mechanisms underlying NBS and
(2) similar, more common disorders, such as esotropia begin to define accurate criteria for its diagnosis.

Case Reports
From the Ocular Motor Neurophysiology Laboratory, Cleveland Case 1
Veterans Administration Medical Center, the Department of Neu-
rology, Case Western Reserve University School of Medicine,* and A six-year-old girl had nystagmus that was first no-
the Department of Ophthalmology, University of Miami School of ticed at the age of three months. Her mother also had
Medicine.t noticed at an early age that she had a tendency to turn
Supported, in part, by the Veterans Administration. her head to either side. Esotropia was suspected early
Submitted for publication: March 7, 1983.
Reprint requests: L. F. Dell'Osso, PhD, Ocular Motor Neuro-
but never treated. Birth had been normal, but early
physiology Lab (127A), Veterans Administration Medical Center, development was delayed slightly. Because of this delay,
Cleveland, OH 44106. mild spasticity in the legs, and nystagmus, she under-


when reading the chart with her right eye. 12 NYSTAGMUS BLOCKAGE SYNDROME / Dell'Osso er ol. ignate fixation of the target by both eyes. She was myopic and had a history of were made for each eye. she had an esotropia of 8-10 imply "binocular fixation. nystagmus wor.4 agnosed. she had 10 prism diopters of esotropia bration. Her parents had noted nystagmus in ad. University right eye and vice versa. Most beats were jerk right. she suppressed study hereditary CN. eyeglasses were in Figure 1 were predominantly jerk and jerk with prescribed. she had a variable 20-40 prism diopters of mus at all gaze angles of interest was recorded. Our examination turned her head to the right when reading with the at the Division of Neuro-Ophthalmology. left esotropia. its fast phase beating in the sphere O. revealed a preference to turn jerk type of nystagmus was seen when the eyes were her head to either side. Later. using infrared oculography. In this way we could align exactly the tracings with her face turned in the direction of the fixating for each eye on the target and then.50 +1." a term that we use to des- prism diopters with 3-4 of left hypertropia in the pri. (her grandparents were first cousins and both the ma- ulogram. She read the visual acuity chart occluded. ments were recorded both during the act of convergence beating when the right eye fixed and left-beating when and the return to distance viewing. cerebrospinal fluid. with a full-system band- width (position and velocity) of DC to 100 Hz (Bio- Case 2 metric Model-200 and rectiliner Beckman Type-R Dynograph. a few dition to her esotropia at a very early age. In addition to the the left eye fixed.1 we have used similar methodology to 4 dot fusion up to 4 feet. beyond that. Without cor. Bin- screen were normal. at three years of age. Simultaneous position and velocity recordings Eye Institute. Her discs and maculas whether pupillary constriction accompanied adduction appeared normal and retinoscopy values were +0. and 20/40 for the left eye. Nystagmus. both eyes. She to correct mild myopic astigmatism. 1581 went neurologic evaluation at age six months: ventric. The waveforms shown months of age but not treated. she had Worth study of MLN. Pupils were was noted on cover test during this examination despite equal and equally reactive to light.00 X 40. Then. She was diagnosed clinically as hav. visual acuity more to the left than to the right and ceased when she was 20/40 in both eyes. Afine. On clinical examination. Stereopsis was absent. Note that both eyes were fixating the history included both consanguinity and nystagmus target which was in primary position (ie. emitting diode as it came on and the ongoing nystag- rection. with correction was 20/30. was not diagnosed.No. The family were jerk left. The term "binocular viewing" is and her face turned to the right shoulder. previous observations of esotropia and its subsequent tagmus and dark irises.3 and the effects her left eye.50 +1. right gaze and left-beating in left gaze.50 of either eye. she appeared a near target-induced convergence and the eye move- to have latent nystagmus. Cycloplegic Recordings were carried out in subdued light and each retinoscopy was: right eye. The patients were seated in variable esotropia since at least one year of age which a chair with a head brace and chin rest at the center had not been treated. On sensory testing. After cali- mary position. when the cover eye. the visual acuity of the scan was also normal. Because of the nys. left eye. The child was given spectacles right eye was 20/50. fixating on an eyes were open with neither occluded. both modified to achieve the above band- A 14-year-old girl was seen at the Bascom Palmer widths). Horizontal eye movement recordings were made ing NBS. which was removed. we were unable to determine documentation by recording. Right esotropia had been noted at 2Vi distant target were those of CN. No specific treatment was advised.U. No strabismus sened and vision became 20/60 bilaterally. shefixatedwith the right eye in adduction binocular viewing. a CT ocular visual acuity was 20/40.pendular or left-beating Hospitals of Cleveland. With the head in either of these in the primary position. of CN surgery. Results Case 3 Case 1 A 10-year-old girl was seen at the Bascom Palmer Waveforms recorded during binocular viewing of a Eye Institute.00 X 135. increased as that eye ab. ducted and the esotropia lessened and decreased when the fixing eye adducted to a maximum esotropia of Materials and Methods 36 prism diopters. On examination. Later. By prism used in this paper to describe the condition where both cover measurements with correction. NBS was not di. eye was calibrated individually while the other eye was +6. the nystagmus being right. there was no . +5.2 CN waveforms. It diminished on lateral gaze positions and the fixing eye adducted. When her head was held converged. and amino acid ternal grandmother and mother had nystagmus). detect even the smallest tropias during she preferred. and it does not accommodative target. Her nystagmus became right-beating in straight in relation to the eye chart. extended foveation. the visual acuity of a five-foot arc containing red light-emitting diodes. NBS direction of the fixing eye. the patients were asked to view each light- with 6 of left hypertropia at distance.

there was no became esotropic the nystagmus abruptly shifted to conversion to MLN and the change with convergence jerk left MLN (reflectingfixationby the left eye alone).1582 INVESTIGATIVE OPHTHALMOLOGY b VISUAL SCIENCE / December 1983 Vol. As the target moved across a consistent null that could be exploited therapeutically. L = Left. and a strong superimposed latent component to the During thisrighteyefixationthe nystagmus waveform . much larger in converged and therighteye became less esotropic until amplitude (10-12°). target fove. 24 pos Fig. Occasional expo- nentially increasing runaways to the right gave rise to large jerk-left beats. right gaze. Recording showed all waveforms to be CN. R = right. Thus. initially fixated with the left eye (the right eye was creasing runaway to the left (ie. esotropia). with of the fast phase (after the dynamic overshoot if one no MLN. the midline to the left. For some cycles. She ation usually was followed by an exponentially in. she assumed fixation with the right eye This patient had a combination of CN. The eyes were on target just after completion CN. the target at 15° to the right was being position. of CN. and b = blink. Therefore. RE = right eye. aflattenedportion (the period with convergence. Then. and as the target came back towards midline. the right eye again achieved target foveation. she chose to change fixation from left eye to her right Figure 3 illustrates the use of the adducting eye to eye when in bright light. In this way the nystagmus was minimized Initially she wasfixatingwith the left eye and had jerk since the fixating eye was always the adducting eye. the left eye also occasional runaways to the right. In this example. she followed it with her right eye while the fixated binocularly (without esotropia) and the patient left eye remained esotropic and had a jerk right with had CN as shown in Figure 1. There were CN waveform. (at the first arrow) and the left eye became esotropic. the tracking was done with the Figure 5 documents the retention of CN waveforms right eye. as the right eye extended foveation CN waveform. As the right eye drifted toward the pri- Case 2 mary position. left with extended foveation waveforms (the right eye was esotropic). esotropia. that was moved from distance to near and back. was a typical example of convergence-induced damping This persisted during the time the right eye was eso. Figure 4 shows the sequence of of extended foveation) existed when the eye remained events that transpired as the patient viewed a target motionless on the target. of patient 2 as she viewed a target in primary position the left eye picked it up and tracked it throughout and alternately shifted between right and left esotropia. the eyes moved with esotropic) and had a jerk left with extended foveation increasing velocity away from the target). at near she had very little nystagmus and was fixating Figure 2 illustrates a truly remarkablefindingin this binocularly. The wave- forms are CN and are mainly jerk-right with extended fo- veation. 1. despite the accompanying esotropia. and that her nystagmus damped significantly existed). Initially. As the target came closer. As the target moved back to the distant case. Although tropic and immediately converted back to CN when this patient had a null at 20° right gaze in dim light. she did not have pursue a moving target. LE = left eye. Position (pos) and velocity (vel) recordings of the eye movements of patient 1 during binocular viewing of a distant target. In this and all other figures.

Then. She had an alternating esotropia and fixated nystagmus (CN). When viewing a target at dis- right eye fixation with the left eye esotropic and her tance. Although she was an alternate fixer. The significant findings for began a period of wandering during which time they this patient also are listed in Table 1. jerk right with extended foveation. Figure the right eye esotropic and exhibited left pseudo-cycloid 7 shows the complete nulling of this patient's nystag- waveforms. both eyes while the target was near. This patient also had only CN waveforms with no It is extremely important in the study of congenital MLN. v—^ LE vel m was jerk right with extended foveation. As the eye converged the nys- viewed a target in primary position with a jerk right tagmus stopped completely and remained suppressed with extended foveation waveform. RT multaneously on target (ie. some of the fast tended foveation. 1583 pos RE vel Fig. When the target was her waveforms were always CN and not MLN. She initially inating the esotropia. the left eye was esotropic and the waveform was waveforms were both jerk right and jerk left with ex.3 The slight distortion in an effort to better define this condition and uncover seen at the extreme right-most portions of the right its underlying ocular motor mechanism. I sec beating MLN which persisted pos until the esotropia disap- peared. 2. Position (pos) and I velocity (vel) recordings of both eyes (patient 1) during binocular viewing of a target 15° to the right. phases had dynamic overshoots. At the third arrow she switched back to mus with convergence. no esotropia). At the second with her adducted eye in both left and right gaze. eye tracing were caused by the infrared system being we also have applied these same oculographic tech- driven out of its linear range (beyond 25°). While viewing the target. After four seconds of this wan- dering she was instructed to view a target at 15° to Discussion therightwhich she did immediately using a 20° saccade followed by a 10° slow phase movement to foveate We have used quantitative oculography to study a the new target. her CN wave. In addition. As the right eye 400%ec became esotropic. the left eye position remained relatively Figure 6 illustrates the fact that this patient could constant and therighteye converged to the target elim- be perfectly binocular in her fixation. remained conjugate. patient with the nystagmus blockage syndrome (NBS) form was left pseudo-cycloid. brought near. the CN abruptly changed to left. latent and manifest latent nystagmus .No. The wave- 1r forms are CN at the begin- ning and end of this illustra- tion when both eyes were si. niques to the study of two patients whose clinical symptoms are similar to NBS and who represent the types of CN patient that we feel could easily have been Case 3 suspected clinically to have NBS. She arrow she abruptly switched to left eye fixation with had a nystagmus null between 0-5° left gaze. 12 NYSTAGMUS BLOCKAGE SYNDROME / Dell'Osso er ol.

1584 INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE / December 1983 Vol. it has been difficult to properly is still not done routinely by many who study nystag. the ad- ducting eye assumed fixation and tracked it. and strabismus.5 Since that time. the nystagmus became CN with a jerk-right with ex- tended foveation waveform. we extracted the Fig. 24 pos r ' • frf Fig. the left eye remained esotropic as the right eye tracked. «-rf1 (LN/MLN). and the rnrrrrrrrnir'trv nystagmus continued to be CN with a jerk-right with ex- tended foveation waveform.1 accurate ocular motility recordings and is based solely This has never been done for NBS and. where the appeared in the literature. on clinical observation. As the target moved in to a near position. 3. the right eye was esotropic and the nystagmus was CN with a jerk-left with extended fove- ation waveform. We have found that many nys- while the other is behind cover). ther exactly what constitutes NBS. when viewing the eye Cuppers. As a result. As the target was moved back to the distance position. several other reports have movement data. characterize the ingredients that make up NBS. Position (pos) and velocity (vel) recordings of both eyes (patient 1) during horizontal tracking of a slowly moving target. to accurately calibrate Speculations arising from such data are suspect and each eye individually (ie. unfortunately. As the target moved across the mid- pos line in each direction. Position (pos) and velocity (vel) recordings of both eyes (patient 2) during binocular viewing of a target which was moved from dis- tance to near and back to distance. . The mus. eye relative to the target may be determined so that Because most of the literature on the subject lacks any small tropia (variable or fixed) can be identified. 4. Initially. when viewing monocularly difficult to support. neither the readers nor the authors syndromefirstwas identified in 1966 by Adelstein and of such studies can be sure. exactly where each eye is. or which eye actually is fixating the target.6"13 In attempt to clarify fur- target is. In this way both the tagmus patients have small variable tropias that are nystagmus waveform and the actual position of each missed on clinical examination.

in fact. Position (pos) and velocity (vel) recordings of both eyes having LN when. Hoyt. 12 NYSTAGMUS BLOCKAGE SYNDROME / Dell'Osso er ol. to MLN. some have claimed that NBS is the result of an induced convergence (or esotropia) whose sole purpose is to reduce an ongoing nystagmus ("nystagmus blockage syndrome") and others have held that an underlying esotropia is responsible for the syndrome.2% in Europe and 4-5% in America) as well as over-diagnosing in conjunction with a lack of quan- titative data. At no time during these fixations or during the wandering did the patient's esotropia become manifest." a term commonly used to de- scribe the dissociated nystagmus of internuclear ophthalmoplegia. jerk-left with ex- tended foveation. Binocular fixation and the CN waveform. 6. with Alexander's Law. Although Metz and Smith13 do discuss NBS. CN waveforms In Case 1 we saw a conversion from CN. Initially.14 in a paper that contained no eye movement recordings. and the diagnosis of NBS cannot be ver- ified. the recordings clearly show that their patient had manifest latent nystagmus (MLN)1 and that the MLN amplitude varied in ac- cordance with Alexander's Law. nystagmus (type unspecified). At the first arrow the left eye became esotropic. when both persisted throughout. and at two distinctly different abnormalities involved in NBS. Only the work of Kommerell8 contains an accurate NBS eye movement recording. the right eye was esotropic. eyes were parallel. both eyes began a 300 CN and MLN patients. the third arrow the left eye became esotropic again.No. recordings revealed that she of patient 3. Based on our experience in recording over in primary position and had CN with jerk-right with extended fove- ation waveforms. Indeed. Position (pos) and velocity (vel) recordings of the CN paper. waveforms of patient 2 during binocular viewing of a target in primary Our recordings have documented the existence of position. resulted. 1585 following signs that were cited in the majority of these reports: esotropia. at the second arrow the right eye. Hoyt's patients certainly did not have "ab- duction nystagmus. Without accurate ocular motility recordings of the various patients discussed by these authors. and an increase in the magnitude of the (jerk) nystagmus with abduction of the viewing eye. we can only add the patient presented by Kommerell8 to our discussion of the pa- tients that we have recorded and presented in this Fig. claimed that eight of 32 patients with congenital esotropia had NBS. In the middle of the tracing. our patient 2 was diagnosed clinically as Fig. a head turn. Initially. and did not have NBS in agree- ment with Kommerell8 who cautions that NBS should not be confused with infantile esotropia accompanied by MLN. we suspect that Hoyt's conjugate wandering until the point at which the patient was in- patients all had MLN. which varied in accordance structed to view a target 15° to the right and made a saccade to that target. Authors who have written about NBS seem to be divided into two camps. but even this paper does not have the type of simultaneous bin- ocular recordings of the one NBS patient presented that would allow us to determine the exact position of each eye relative to the target. when one eye became . the patient was binocularly fixating a target had CN. it is impossible to know if they were talking about the same entity. Therefore. 5. The reported incidence of NBS in esotropic patients 09- is quite variable and seems to reflect a geographical bias (10. Without recordings CN cannot be differentiated from MLN.

24 substantially reduce the nystagmus amplitude. foveation. and DJ = dual jerk. PC = pseudo-cycloid. LE We propose. the CN nulled completely. null was not consistent. The esotropia may reduce the nys- converged on the target that was moving to a near position along tagmus by one of two mechanisms: it may convert the the midline. T = triangular. Kommerell's8 ner as true binocular convergence reduces the ampli- NBS patient constantly had CN waveforms whether tude of CN in many patients (Kommerell's case and the eyes were parallel or one was esotropic. disclosed the MLN (when similar to NBS. the two have measured the variable angle of esotropia and il- non-NBS patients we have presented. J EF) PC) NO* YES/NO 20°R§ AET. Therefore. exhibited only CN waveforms. J = jerk. F CN YES (J. § Fixated with OD in bright light and OS in dim light (our lab) so that her * Nystagmus changed from CN to low amplitude MLN. tropia. F NBS YES (P. In contrast. This patient's visual acuity pos is better with MLN only because her MLN is of much lower amplitude than her CN. our NBS patient became esotropic In addition. TRUE/ET Null Angle 1° Tropia suppression 1 6. it was thought that she might have NBS. fully described this syndrome. and doc- Table 1. Likewise. quantitative eye movement recordings but showed no true convergence.1 it is rare to find a patient who has vel better acuity during the MLN waveforms than during the CN waveforms. The utilization of a very low am- TR plitude MLN to enhance visual acuity has not been 2ff400rsec described previously. In contrast to our patient. t Fixation was with adducted eye in left and right gaze. When viewing the (ie. P = pendular. The combination of CN.1586 INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE / December 1983 Vol. As the patient an added esotropia. we have accurately de- the waveforms are CN with no MLN during the eso. Most CN waveforms have in- k creasing-velocity slow phases and much longer periods of foveation time (>100 mseconds) per cycle then MLN. or it may reduce an ongoing CN much in the same man- esotropic. J EF . Position (pos) and velocity (vel) recordings of both eyes NBS is indeed a "blockage" of an ongoing nystagmus of patient 3 during the process of convergence. In Kommerell's figure. binocular ocu- to increase an esotropia at distance and reduce the lography. Until more patients NBS patient differs from most with CN by the ability with NBS are studied with quantitative. EF = extended $ Had superimposed latent effect on her CN but no MLN. RE While it is not rare to find patients who have both CN and MLN. 7. This latter another which we have recorded). L = left. were able to converge binocularly and fixing eye appeared motionless to clinical observation). true Fig. J. we cannot say with certainty that we have nystagmus without diplopia. nystagmus to a very low amplitude MLN (Case 1). on the basis of our and Kommerell's8 findings. the left was esotropic and the nystagmus was CN with a jerk-right with extended foveation waveform. . who had signs lustrated its time course. and a strong super- imposed latent component (patient 2) makes diagnosis difficult. CN) present with both eyes parallel. esotropia. R = right. Patient data \N\ i with convergence Age (yr) Clinical Visual Patient and sex diagnosis CN/Waveforms MLN . scribed two variations of it. and at one point. HT (OS)§ YES 3 10. that the diagnosis of nystagmus blockage syn- vel drome be made only when the ongoing waveform is of CN (with both eyes parallel) and when the nystagmus r markedly diminishes with esotropia. PC. Their esotropia did not demonstrated the crossed fixation pattern. T) YES NA/YES* NONE AET(ALT)f YES 2 14. The strong superimposed latent pos component could have easily been misdiagnosed as latent nystagmus. which has decreasing-velocity slow phases and minimal foveation time. F CN YES (J. JEF) NO YES/NO 0-5°L ET (OD)f YES A = variable. produced by target at distance.

von Noorden GK: The nystagmus blockage syndrome. Frank JW: Diagnostic signs in the nystagmus compensation syndrome. This is little emphasized in the literature but 12. pp. J. their accommodative vergence mechanism to block Bergmann. and augmentation scheinbaren Abducenslahmung (das sogenannte "Blockierungs- syndrom"). The large discrepancies in re. albeit disputed. 1975. 1976. of the fixating eye remains exactly the same under 9. manifest latent. of pupillary constriction. Also. editor. Austral other mechanism to bring about damping of the nys. the eye) when the eye assumes its adducted position 8. Arch Ophthalmol 97:462. eye movement recording 1974. 10. mechanisms are in play. editor.No. one or the other eye is adducted. indicating that no accommodative syndrome." this complex syndrome. congenital nys- many patients with MLN (manifest because of am. 1. Metz HS and Smith G: Abduction nystagmus. Kommerell G. Dell'Osso LF.5 The accommodative state 164:172. nystagmus when the fixating eye is abducted by dis. In Augenmuskellahmungen. Kommerell G: Nystagmusoperationen zur Korrektur verschie- to block the nystagmus. the nystagmus but instead. 1978. 1587 umented the MLN reduction with adduction. pp. Hoyt CS: Abnormalities of the vestibulo-ocular response in con- dicated that his NBS patient was "rare" (we have seen genital esotropia. nystagmus: an intrafamilial study. damping of the nystagmus when quantitative evaluation of the effects. Am J Ophthalmol 82:283. 5. 1979. The only two cases in over three hundred recorded with value of eye movement records for characterization. Stuttgart. 12 NYSTAGMUS BLOCKAGE SYNDROME / Dell'Osso er ol. sual inspection of the patient. Klin other forms of convergence excess is the size of the Monatsbl Augenheilkd 157:500. 271-278. F. able that over-diagnosis is caused by the absence of quantitative eye movement data and the inclusion of Key words: nystagmus blockage syndrome. and understanding the mechanism of "we need more electronystagmographic tracings to NBS is complemented by its critical use in diagnosing learn more about the mechanics of this syndrome". nation of esotropia and MLN. Verlag. 1966. are depending upon some 11. Arch Ophthalmol 97:1877. Adelstein F and Cuppers C: Zum Problem der echten und appearance of the angle of squint. nosed and often confused with the common combi- ica) suggest the absence of uniform criteria. Am J Ophthalmol 93:704. Ophthalmol Strabismus 15:312.9 clinical diagnostic 13. Dell'Osso LF and Daroff RB: Congenital nystagmus waveforms and foveation strategy. 3. tagmus. latent nystagmus. 1970. In summary. measurement. Cuppers C: Probleme der operativen Therapie des okularen Nystagmus. Miinchen. 1979. pupils (and presumably the accommodative state of 7. 1982. Buch d Augenarzt Heft of the angle of convergent squint when a base-out 46. Klin Monatsbl Augenheilkd. and congenital nystagmus. References wards the fixing eye) would increase with abduction and decrease with adduction. 6. J Pediatr point. von Noorden GK: The nystagmus compensation (blockage) these circumstances. Kommerell G: Relations between strabismus and nystagmus. esotropia blyopia or suppression in one eye). we agree with Kommerell8 who in. Schmidt D. 1978. the decreasing-ve. Arch Ophthalmol 92:366. . These patients are not using In Disorders of Ocular Motility. Doc Ophthalmol 39:155. 1979. J Ophthalmol 7:31. 14. worsening of the 1979. is necessary. In accordance with Alexander's Law. prism is placed before the fixating eye. It is prob. the MLN (whose fast phases are to. Haase W: Zur Diagnose und Therrapie des Nystagmusblocki- another useful clinical sign in differentiating NBS from erungsyndroms (elektromyographische Untersuchungen). The well-known hallmarks of NBS are: a variable 4. In addition. Dell'Osso LF. locity slow phases of MLN cannot be distinguished 2. Dell'Osso LF and Flynn JT: Congenital nystagmus surgery: a angle of esotropia. and Daroff RB: Latent. J Pediatr Ophthalmol Strabismus 16:317. Flynn JT. and Daroff RB: Hereditary congenital from the increasing-velocity slow phases of CN by vi. is an important. tagmus. We also share their opinions that NBS is over-diag- ported incidences (10% in Europe and 4-5% in Amer. Klin Monatsbl Augenheilkd 159:145. There should be no evidence dener Kopfzwangshaltungen. Enke F. 1971. 367-372. CN and/or MLN) and with von Noorden who stated. 1974.