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Eye Movements.
test 2. Aquired Nystagmus, Medulla, Pons, Midbrain, Cerebellum, Cerebral Hemispheres, Ataxia & Apraxia
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06/30/2013

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Term
Medulla Abnormalities...cause what?

4 Associated conditions?
Definition
General shift toward one side. Upbeat nystag.

Lateralpulsion
Wallenberg
Oculopalatal Tremor
Medulary Lesion
Term
Pons Abnormalities...cause what?

4 Associated conditions
Definition
Eyes can't cross the midline when looking at the side of the lesion. (horiontal gaze palsy)

PPRF (Parapontine Reticular Formation)
Abducens Nuclear Lesion
INO lesion - in the MLF
Combined lesions (1.5 syndrome)
Term
Cerebellum Abnormalities...cause what?

Which 4 parts of the cerebellum have issues

5 conditions
Definition
Saccadic over/undershoot. Jerky movments. Downbeat nystag.

Dorsal Vermis
Fastigial Nucleus
Flocculus & Paraflocculus
Nodulus and Uvular

Lateropulsion/Wallenberg (also in Medulla).
Cerebellar infarction.
Congentital malf- Arnold Chiari, Dandy Walker, Walker Warburg
Term
Midbrain Abnormalities...cause what?

Associated conditions (midbrain only)

Other 6 conditions (that involve other parts of the brain too)
Definition
Vertical probs. Fixation instability. INO (eso)

Basilar Syndrome, Dorsal Midbrain, Intersitial nucleus of Cajal, Lesions

PSP, Whipple, MS, Wernicke, Alzhimers, AIDS
Term
Cerebrum Abnormalities...cause what in which lobe?
Definition
Frontal Lobe- inaccurate sacades
Parietal- one sided and innatention issues
Occipital-Local (MST,V3) and Global motion (MT) pursuits
Temporal- Midline shifted (also in Interstitial Nucleus of Cajal, midbrain)
Term
Downbeat Nystagmus

(a type of central vestibular nystag)
Definition
Drift up, beat down
Worse in downgaze

Posterior Canal, head pitch

Arnold Chiari
Cerebellum prob
MS
Meds, idiopathic

Treat: Maybe: BO prism BACLOFEN, Acetazolamide
Term
Upbeat Nystagmus

(a type of central vestibular nystag)
Definition
Drifts Down, Beats up. Upgaze makes worse. Abnormal Pursuits.

Anterior Canal, or Superior Cerebellar Peduncle, or Pons/Brainstem junction.

Cause: Cerebellar degeneration or stroke, MS, Infectious or a tumor

Treat: harder than downgaze:
4-aminopyridine, Clonazepam, BI or BO
Term
Torsional Nystag

(a type of central vestibular nystag)
Definition
Beats away from the lesion.

Why: Anterior and Posterior Canal Projections

Cause: STROKE, MS, Arnold chiari, Angioma

Treatment: Underlying disorder,
mabye Gabapentin, Baclofen clonezapam.
Term
Seesaw

(a type of central vestibular nystag)
Definition
One eye intorts and elevates, the other extorts and depresses.
(Hemi-seesaw, associated w/ position and otoliths)

Location: INC and Chiasm

Cause: Pituitary Adenoma, TIA, Trauma

Treatment: BACLOFEN, Clonazapam, Gabapentin, Alcohol?
Term
Periodic Alternating Nystag (PAN)

(a type of central vestibular nystag)
Definition
Beats to one side, then after a few seconds beats to the other side.
Lesion in Flocculus and Nodulus. (they tend to have WTR cyl)

Cause: MS!!, Albinism, Arnold Chiari.

Treatment: BO prism, convergence may dampen.
Term
Positional Nystag

(a type of central vestibular nystag)
Definition
Position evoked (pseudo -BPPV)
4 types
Term
Eccentric Gaze Nystag
Definition
Gaze evoked is most common: move eye into lateral gaze, and it beats away from center.
Treatment: Alcohol, anticonvulsants/depressants.

AND if moved toward primary gaze, beat the opposite way. (CENTRIPITAL/ REBOUND saccades).

OR Dissociated- one eye goes "come on! come on!)
Term
Aquired Pendular Nystagmus (APN)
Definition
NO FAST PHASE. Looks like a general eye wobble. Horizontal/vertical/the works.

Leber's Rod-cone, MS, INO

Treat: MEMANTINE!! Clonazepam, valproate ,scopolamine
Term
Developmental Nystag (Infantile)
Definition
Different manifestations
Horizontal and conjugate jerk, patient tilted to one side. Maybe PAN. Backwards OKN! Beats away from occluder

WTR Astigmatism (b/c of PAN). Associated w/ Albinism (macular pigment prob)

Treat: w/ yoked (base in direction of head turn). Or BO. Or Kestenbaum
Term
Latent Nystagmus (Fusional maldevelopment)

(Developemental)
Definition
Cover right eye and left eye will beat left. Cover left eye and right eye will beat right.

**ESO tropia! and DVD!!

Take VAs by fogging.

Treatment:
Resection of MR maybe (not emphasized)
Term
Spasmus Nutans

(Developmental Nystagmus)
Definition
Sontaneously beginning and ending (a few years later). Fast pendular eye movements. Bob their head.

Rule out tumor w/ MRI
Term
Aquired Vs. Congenital Pendular Nystagmus
Definition
Aquired: sinusiodal curve pattern, frequently dissociated, can be vertical and torisional, OKN is normal, Frequently have oscillopsia.
Congenital: irregualar pattern, eyes move together, ONLY HORIZONTAL, OKN reversal, no oscillopsia.
Term
Botox
Definition
Use for: EOM overreactions, palsies, nystag
Conditions: MS, stroke, myoclonus nystag.

Lasts months, works best w/ aquired nystag
Term
Prism
Definition
BO- Used to induce convergence dampening (Dbeat, Upbeat, PAN!!)
Yoked- to image shift (infantile PAN)
Term
Kestenbaum
Definition
Tightens the reigns. Use when they have a head turn.
Infantile/Latent onset Nystag (congenital)

Doesn't dampen nystag. Used on Torticolis
Term
Four-muscle Tenotomy
Definition
Cut all the muscles, put them back and hope the nystag goes away.
Term
Acetazolamide
Definition
Downbeat nystag
Arnold Chiari
Gaze-evoked Meneirs

Normally used for: Glaucoma, Meneirs, Pseudotumor ceribri, Arnold chiari

SULFA!!!
Term
Aminopyridines
Definition
Downbeat nystag

K channel blocker- MS, bird pesticide
Term
Baclofen
Definition
MOST COMMON MED FOR NYSTAG. Upbeat, downbeat, Seesaw, PAN, Torisonal
Term
Clonazepam (short term)
Definition
SeeSaw (Chiasmal)
APN
maybe upbeat and torisonal.

Normal Use: Seizures, panic, anxiety.
Term
Gabapentin
Definition
APN!
maybe Seesaw, torisional, Oculopalatal tremor

Used for Epilepsy, neruopathic pain, marketed for suicide but not good.
Term
Memantine
Definition
APN (especially due to MS)

Might protect ganglion cells.
Crosses bbbarier
Alzheimer's
Term
Scopolamine
Definition
APN

Used normally for Parkinsons, GI spasm, Truth serum
Term
Valproate
Definition
APN (but Memantine is drug of choice for that)

Normally for crazies and epileptics. Don't take when preggo.
Term
Treatment for nystag: Skills vision therapy
Definition
Enhance BV. Anti-suppression. Therefore decreasing nystag
Term
Treatment for nystag: Visual Biofeedback
Definition
Glasses that help you focus with lights. Moves null point to the right place.
Term
Treatment for nystag: Auditory Feedback
Definition
Patient can hear nystag.
Term
Treatment for nystag: Amblyoscope/Synoptophore
Definition
Major amblyoscope. Flashes a red light for several minutes. takes weeks, but long lasting effect.
Term
Review of convergence (erin d. and Erica W.)

4 convergence issues
Definition
REVIEW OF VERGENCE
Case Review of Convergence (Erin Davis, and Erica Wiegandt)
INO: disorder of conjugate lateral gaze. Affected eye cannot ADDUCT
The non-affected eye displays nystagmus on ABDUCTION (trying to recruit)
Convergence is spared
Cause: older adults = lesion of MLF. Younger adults = demyelinating disease (MS)

Convergence Retraction Nystagmus: co-contraction of MR muscles
Jerk nystagmus induced by downward OKN stimulation.
Upward refixation brings the two eyes together
Cause: Parinaud Syndrome (lesion of upper brainstem. Paralysis of up-gaze)

Whipple: bacteria. Symptoms: malabsorption, wt loss, arthritis. M > W. Antibiotics.

Argyll-Robertson Pupil: constrict w/ accommodative convergence, but not with light
Edinger-Westphal nucleus (responsible for pupil constriction, accom, convergence)
Clinically: test accommodative convergence in pt that has tonic pupils to DDx.
Causes: not just neurpsyphilis. Parinaud. Brain injury. Thiamine (B12) Deficiency.
Term
Lateropulsion

(Medulla)
Definition
Upbeat nystag. Eyes beat drift toward lesion (corrective saccades away?)

Whole body drifts (hiccups, polydactyly)

Treat: yoked prism.
Term
Wallenberg Syndrome
Definition
-Vertical saccades are oblique. Head tilt toward lesion.
-Hypermetric saccades toward leison, hypometric away.
-Drift to the affected side when eyes closed
-ipsilateral ptosis and horner's

-SKEW deviation (looks like 4th or 3rd nerve)

Where: Dorsal medulla

From: Ipsilateral vertebral artery occlusion, Posterior inferior cerebellar artery occlusion, Vertebral artery dissection, MS
Term
Oculopalatal tremor
Definition
APN! with palate tremor

Treatment: Gabapentin

STROKE

Problem in: Central tegmental track, Olivary nucleus (medulla), red nucleus (midbrain), Dentate nucleus (cerebellum)
Term
Medulary lesion
Definition
Upbeat Nystag. Downdrift of eyes. Horizontal. Gaze evoked nystag.

Prob in: anterior canals pathway interrupted
Term
Abducens Nuclear Lesions
Definition
Horizontal gaze palsy. Cant look to the side with the lesion in either eye.
Term
PPRF lesions
Definition
Slowed saccades toward side with lesion. (Pons)
Term
INO (in MLF)
Definition
Unilateral: Eye on the side of the lesion can't cross the midline.

Bilateral: neither eye can cross the midline when looking toward the opposite side.

But they can when converging!

Cause: Stroke, MS, tumor, arnold Chiari
Term
One and a Half Syndrome
Definition
pons

INO+6th nerve prob.

Only one eye can abduct. But it works when converging.
Term
NRTP (Nucleus Reticularis Tegmenti Pontis) lesions
Definition
INO + impaired vergence. (pons)

Torisional saccades. Maybe exo.
Term
Basilar Syndrome
Definition
Unilateral: Slow or Palsy of down-saccades
contralesional down-nystag

Bilateral: No more vertical saccades

Basilar syndome (actually) acute loss of down saccades. and Jocular behavior

Area affected: rMLF
Also -Vertical 1.5 syndrome.
Term
Dorsal Midbrain
(Pretectal/Parinaud)
Definition
Restricted up-movements. CONVERGENCE WHEN THEY TRY AND LOOK PLACES.
Fixation instability.
APD in contralateral eye.

Skew deviation.

Cause: Posterior Commisure lesions! COLLIER'S LID SIGN.
Term
Interstitial Nucleus of Cajal
Definition
Impairs gaze holding. Impairs all vertical movements.

SKEW (tilts AWAY from lesion, as opposed to Wallenberg)
Term
Midbrain Lesion and Abduction
Definition
Thalamic ESO!! lookse like 6th nerve palsy. Lesion is btw the third and sixth.
Term
Progressive Subranuclear Palsy
Definition
Progressively lose verticals, down first.

Condition: Presents like Parkinsons. Ask them to clap 3 times and they can't stop clapping.
Term
Whipple Disease.
Definition
Pendular convergence retraction nystag! Pathepnumonic. Myoclonus. Looks like PSP.
Term
MS
Definition
Bilateral INO, Gaze nystag. Eso mimicking 6th nerve palsy.

All sorts ov other nystags and flutter. Gaze palzies and spasms.

Pred helps w/ visual symptoms, but not ORAL pred.
Term
Wernicke Encephalopathy
Definition
Triad: Ophthalmoplegia, ataxia, "global confusional state"

corrective sacades to make up for bad slow phase response.

Gaze evoked or positional nystag.
Term
Alzheimers and CJD
Definition
Catchup saccades, b/c pursuits aren't working

Saccadic intusions: Poor supression of superior coliculus, and bad attention shifting.

Poor contrast, depth and motion.
Term
AIDS complex
Definition
Increased Latency of vertical saccades
Fixation instabilit
Antisacade error
Apraxia.
Term
Skeffington's four circles of vision
Definition
1. Antigravity- VOR OKN
2. Centering- saccades, magno, vergence
3. Identification- pursuits, parvo, accommodation, fixations
4. Speech and language- Brocas.
Term
Dorsal vermis
Definition
Ipsilateral Hypometria
(cerebellum)
Term
Fastigial Nucleus
Definition
overshoot in the direction of the lesion (like lateropulsion and wallenburg)
Term
Flocculus and Paraflocculus
Definition
Gaze evoked rebound nystag.
Catch up saccades w/ pursuits (like w/ aids)
Bad VOR
Jerky
Term
Nodulus and Uvular Lesions
Definition
PAN
Prolonged VOR
DOWNBEAT.
Term
Vascular Cerebellar Infarction
Definition
Superior Cerebellar artery- Hypermetric contralesional saccades. Hypometric ipsi.

Posterier Inf Cerebel Art- Looks like wallenberg

Anterior inferior Cerebellar art- Gaze pasly Bells palsy
Term
Arnold Chiari Malformation
Definition
congential cerebellum

Downbeat nystag. Worse in lateral gaze

Type 1- adult onset, vermis herniation
Type 2- hydrocephalus, myelomeningocele
Type 3- bad birth defect, neural tube wont close. Teratogens
Term
Dandy-Walker Malformation
Definition
WARFARIN/COUMADIN DURING PREGNANCY.

cerebellum malf. Nystagmus/ strab/ instability
Term
Walker Warburg
Definition
cerebellum congenital

Persistant Hyperplastic Primary Vitreous- Malformaiton of vitesous. glial tissue wrong in the eye. Looks like ROP.

AR. Muscular dystrophy, coloboma
Term
Type 1 and 2 Episondic Ataxia
Definition
Type 1
-Barrel chested kids
-triggered by stress
-eye lid twitch
up to age 20

Type 2- up to age 30
Nystag, VOR OKN saccades pursuits, migrains
Term
Benign Recurrent Ataxia
Definition
Episodes of clumsiness, migrains, and extremely paiful nerualgia
-Triggered by stress, up to age 50
-Peripheral vestibuar nystagmus
-ACETAZOLAMIDE
Term
Spinocerebellar Ataxia
Definition
Degereration of coordination of body and eyes.

Retinopathy, Salt and Pepper fundus.
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