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NEW AVENUES IN MANAGEMENT OF NYSTAGMUS From Dr.Shashank Ranade DNB, DO, DOMS,FCPS,FICO(UK) Fellow, Pediatric Ophthalmology, Strabismus & Ocular motility.

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Presentation on theme: "NEW AVENUES IN MANAGEMENT OF NYSTAGMUS From Dr.Shashank Ranade DNB, DO, DOMS,FCPS,FICO(UK) Fellow, Pediatric Ophthalmology, Strabismus & Ocular motility."— Presentation transcript:

1 NEW AVENUES IN MANAGEMENT OF NYSTAGMUS From Dr.Shashank Ranade DNB, DO, DOMS,FCPS,FICO(UK) Fellow, Pediatric Ophthalmology, Strabismus & Ocular motility disorders [International Guest Speaker, UK] RANADE SUPER-SPECIALITY EYE CENTRE Mumbai Expert panelist talk given at ALL INDIA OPHTHALMOLOGICAL SOCIETY MEET held at KOCHI, February 2012

2 Financial Disclosure I hereby declare that I don’t have any financial interests in any of the products or procedures mentioned in the forthcoming presentation

3 Nystagmus Work-up History taking- Onset, consanguinity and family history Vision assessment- Dilated refraction Slit lamp examination - iris transillumination defects ? Fundus examination - Optic nerve or retinal pathologies ? Eye Movement recordings / EOG / ENG ERG & pVEP- CSNB, Cone dyst, Ocular albinism, ON disorders MRI/ CT Scan and Neurologist opinion -suspected central/sub- cortical causes Genetic analysis -FRMD7 in CIN

4 EYE MOVEMENT RECORDINGS Electo-oculography (EOG) Infrared reflectance (IR) Scleral search coil Video-electronystagmography ( VENG)- Latest & most preferred choice amongst all. Good saccadic resolution and linearity for testing saccades and pursuit, less noisy

5 Various treatment modalities available PRISMS OPTICAL METHODS SOMATOSENSORY / AUDITORY FEEDBACK ELECTRONIC METHODS Fields in which newer PHARMACOTHERAPY avenues have developed SURGERY GENE THERAPY

6 Clinical division of treatment options

7 OLDER- LESSER PRACTICED OLDER- LESSER PRACTICED TREATMENT OPTIONS TREATMENT OPTIONS

8 PRISMS Used in 3 scenario’s- Pre-surgical evaluation purpose Congenital Nystagmus which gets suppressed while viewing near targets- we use 7 D BO prisms Nystagmus with altered head postures- Amount of prism required ( > 30 pd ), hence it obscures functional vision, are cumbersome and cause chromatic aberration. Dell’Osso LF.Developments of new treatments for congenital nystagmus, Ann N Y Acad Sci

9 OPTICAL METHODS More useful in Acquired Nystagmus of Neurological type. It Stabilises the image on the retina through high convex specs coupled with high negative power CL ( RGP, PMMA). Limitations- Disables all eye movements, works monocularly and in stationary state only Field of view -limited Difficult to handle Refinement of an optical device that stabilizes vision in patients with nystagmus, Yaniglos SS, Leigh RJ, Optom Vis Sci, 1992,June, 69 ;

10 AUDITORY/SOMATOSENSORY STIMULI & BIOFEEDBACK METHOD Suppression via trigeminal afferents by using a contact lens over cornea or auditory stimuli over forehead or acupuncture over neck muscles and has been primarily found with some effects in CIN. Biofeedback has not been reported to be useful. Dell Osso,Tracis,Abel,Erzurum-Contact Lens in congenital nystagmus,Clin Vis Sci 1988 ; 3: Sheth,Dell Osso,Leigh,Van Doren-The effects of afferent stimulation on congenital nystagmus foveation periods. Vision Res 1995 ; 35 :

11 ARTIFICIAL DIVERGENCE SURGERY Aim - induce exophoria by bi- medial rectus recessions or recess- resect procedure which in turn the patient overcomes by exerting fusional convergence The former is useful in Congenital nystagmus which dampens on convergence while the later in AHP cases Sedler S, Shallo-Hoffman J, Muhlendyck H. Die Artifizielle-Divergenz-Operation beim kongenitalen Nystagmus. Fortschritte Ophthalmol 1990; 87: Zubcov AA, Stark N, Weber A, Wizov SS, Reinecke RD. Improvement of visual acuity after surgery for nystagmus. Ophthalmology 1993;100: Kestenbaum and artificial divergence surgery for abnormal head turn secondary to nystagmus. Specific and nonspecific effects of artificial divergence, Graf. M, Strabismus, 2002 ; June; 10(2):

12 BOTOX 25 U of Botulinum Toxin A Injection is injected directly into the retrobulbar space. Used in : Acquired Nystagmus ( Post CVA )- reduces oscillopsia and improve visual acuity Effect is short lived (3 to 6 months approx),diplopia and ptosis Might need to cover the other eye to prevent ‘competition/ diplopia’ Helveston EM, Pogrebiank AE: Treatment of acquired nystagmus with botulinum A toxin. Am J Ophthalmol, 106:584, Lennerstrand G, Nordbo OA, Tian S, et al: Treatment of strabismus and nystagmus with botulinum toxin A. Acta Ophthalmol Scand 76:27, 1998 Ruben ST, Lee JP, O’Neill D, et al: The use of botulinum toxin for treatment of acquired nystagmus and oscillopsia.Ophthalmology 101:783, 1994.

13 OLDER – WIDELY PRACTICED OLDER – WIDELY PRACTICED TREATMENT OPTIONS TREATMENT OPTIONS

14 HORIZONTAL RECTUS MUSCLE RECESSIONS Maximal recession of all 4 horizontal muscles i.e, as high BMRc of 10 mm & BLRc of 12 mm First suggested by Briti-Bagolini (1960) but revived by Von-Noorden- Helveston (1991) Not only decreases nystagmus intensity and improve visual acuity but also addresses strabismus and head posture issue effectively after thorough surgical planning. The effect of horizontal rectus muscle surgery on clinical and eye movement recording indices in infantile nystagmus syndrome, Bagheri et al, Strabismus, 2010,June, 18(2) ; Vertical rectus muscle surgery for nystagmus patients with vertical abnormal head posture, Yang MB,Archer et al, J AAPOS, 2004,Aug ; 8 (4),

15 SOURCE- The effect of bilateral horizontal rectus recession on visual acuity, ocular deviation or head posture in patients with nystagmus, BagheriA, Farahi A, Yazdani, J AAPOS, 2005, Oct, 9(5), 433-7

16 RECESS- RESECT PROCEDURES 1953, Anderson and Kestenbaum independantly suggested them. Anderson had mentioned about recession of horizontal rectii,While Gotto had suggested resection, Kestenbaum came with idea of operating all the 4 muscles (5mm) Parks modified it (5,6,7,8) & Calhoun-Harley -Nelson ‘Augmented’ it. The surgery not only shifts the eye to null position to correct AHP but also improves nystagmus waveforms and broaden the null zone Anderson JR. Causes and treatment of congenital eccentric nystagmus. Br J Ophthalmol 1953;37: Kestenbaum A. Nouvelle opération du nystagmus. Bull Soc Ophthamol Fr 1954 Parks MM. Congenital nystagmus surgery. Am Orthopt J 1973;23: 35-9

17 FIG 1. Comparison of preoperative (A) and 3 months postoperative (B) electronystagmogram showing shift of null position from 30° right gaze preoperatively to primary position after augmented Anderson procedure FIG 1 -Prospective Clinical Evaluation of Augmented Anderson Procedure for Idiopathic Infantile Nystagmus,Pradeep Sharma, Vimala Menon, JAAPOS,Aug 2006, 10 (4), FIG 2- Improvement in Visual Acuity Following Surgery for Correction of Head Posture in Infantile Nystagmus Syndrome Vijayalaxmi, A Kumar, J POS, Nov 2011,48 (6),

18 HEAD POSTURE CORRECTION SURGERIES SurgeryIndicationWhat is done ? KestenbaumHead turnBilateral 5mm recess-resect of hor. recti Augmented Anderson’s Head TurnYolk muscle recess ( MR-9, LR-12 ) Classic ParksHead turn upto 30 deg5,6,7,8 Rule Aug Kestenbaum / Classic Plus (Calhoun-Harley) Head turn above 30 degNecessary augmentaions of 40 % and 60 % required ( for 40 and 45 deg resp) Vert Kestenbaum /Parks Chin elevation/depressionBilateral recess-resect of SR & IR Torsional KestenNyst with Head tiltSO & IO surgeries Decker’sSame as aboveVertical transposition of horizontal recti Spielmann’sSame as aboveSurgical slanting of insertion of all 4 recti Von Noorden’sSame as aboveHorizontal transposition of Vertical recti

19 PHARMACOTHERAPY

20 Pharmacology in Nystagmus Name of the drugMode of actionPreferred drug of choice Gabapentin & BaclofenGABA receptor agonistsAcquired pendular nystagmus MemantineNMDA receptor antagonistCongenital Idiopathic Nystagmus 4-AminopyridinesK+ channel blockerVertical upbeat- downbeat nystagmus ClonazepamBenzodiazapine / GABA a receptor agonist CarbamazepineNa+ channel blockerSup Oblique Myokimia Sodium valproateNa+ channel blocker & GABA agonists Pendular nystagmus Acetozolamide & Brinzolamiode Carbonic anhydrase inhibitorInfantile Nystamus Benztropine & Trihexphenydyl Anti-CholinergicOculopalatal tremor PropranololB- BlockerOpsoclonus

21 NEWER- WIDELY PRACTICED NEWER- WIDELY PRACTICED TREATMENT OPTIONS TREATMENT OPTIONS

22 BACLOFEN Useful in- Acquired Pendular Nystagmus ( esp. post fossa tumors and Post MS) Recommended dosage schedule mg TDS Visible changes noted- reduced amplitude of horizontal pendular nystagmus ( 70 % times ), subjective improvement of oscillopsia ( 45 % times ) and visual acuity improvement ( 35 % times ) Side effects- Drowsiness(63%),dizziness (15%), Nausea (12%) Effects of baclofen on upbeat and downbeat nystagmus,M Dietrich, A Straube et al, J of Neurology, neurosurgery and Psychiatry, 1991 ;54 :627-32

23 CASE REPORT 26 yr old, male with h/o horizontal diplopia and dizziness since 2 weeks Confirmed to have right INO with upbeat nystagmus MRI - Hyperintense area in right midbrain tegmentum and anterior cerbellar vermis s/o of inflammatory plaque EEG and evoked potentials were normal Introduced on 5mg TDS dose of baclofen Decrease in nystagmus intensity in primary, right, left, up and down gaze was noticed.

24 GABAPENTIN Useful in- Acquired Pendular–Jerk Nystagmus (esp. Post MS, Post ocular pathology) and CIN Recommended dosage schedule- 300 – 800 mg TDS Visible changes noted- reduced amplitude of horizontal pendular nystagmus ( 95 % times ), subjective improvement of oscillopsia ( 60 % times ) and visual acuity improvement ( 35 % times ) Side effects- Fatigue, dizziness, emotional and behavioral problems in children The effects of gabapentin and memantine in acquired and congenital nystagmus : a retrospective study, T Shery, I Gottlob, Br J O, 2006 ; 90: Gabapentin but not vigabatrin is effective in acquired nystagmus in multiple sclerosis, F Bandini, E Castello et al, Journal of Neurology Neurosurgery Psychiatry, 2001; 71 :

25 CASE REPORT 60 yr old, male, K/C/O Multiple sclerosis Presented with elliptical pendular nystagmus BCVA -OD 6/24, OS 6/60. Patient put on oral gabapentin. Started on 300 mg TDS and since the patient was able to tolerate with inadequate response the dosage was further increased to 800 mg TDS. BCVA improved in OD to 6/12 OS to 6/18. Nystagmus amplitude also showed 50 % improvement. Now almost 6 years he is still on gabapentin with good tolerance and consistent response. After GabapentinBefore Gabapentin RIGHT EYE LEFT EYE Source- The effects of gabapentin and memantine in acquired and congenital nystagmus : a retrospective study, T Shery, I Gottlob, Br J O, 2006 ; 90:

26 NEWER- FUTURE TRENDS NEWER- FUTURE TRENDS

27 MEMANTINE Useful in- Congenital idiopathic nystagmus, Acquired pendular Nystagmus ( even those refractory to gabapentin ) Recommended dosage schedule mg BD Visible changes noted- reduced amplitude of horizontal pendular nystagmus ( 70 % times ), subjective improvement of oscillopsia ( 45 % times ) and visual acuity improvement ( 35 % times ) Side effects- Dizziness(7%), headache (6%), confusion (6%), constipation(5%) The effects of gabapentin and memantine in acquired and congenital nystagmus : a retrospective study, T Shery, I Gottlob, Br J O, 2006 ; 90:

28 Memantine dosage schedule ( Source- Dept of Ophthalmology, Leicester Royal Infirmary,England) New cases 10 mg BD for 56 days If responds adequately Shift to maintenance dosage 10 mg OD If response is poor / inadequate Increase the dosage to 20 mg BD for 56 days If responds, shift to maintenance dose Maintain on 10 mg BD dose

29 CASE REPORT 65 yr old, male with c/o oscillopsia, ataxia, hyper-reflexia of right extremities MRI showed plaques CSF confirmed the same Diagnosed with MS Started on gabapentin 300 and then 800 TDS with poor response Patient was shifted to memantine 10 mg TDS and showed a spontaneous improvement in nystagmus intensity. RIGHT EYE LEFT EYE GabapentinMemantine AFTER TREATMENTBEFORE TREATMENT Source- The effects of gabapentin and memantine in acquired and congenital nystagmus : a retrospective study, T Shery, I Gottlob, Br J O, 2006 ; 90:

30 4- AMINOPYRIDINES A latest study by Strupp et al established the role of 4- Aminopyridines and 3,4-diaminopyridines in Upbeat nystagmus secondary to any lesion between pathway from vestibular to oculomotor nuclei Reduction in oscillopsia and improvement in upward smooth pursuit movement during attempted fixation in daylight ( abolished in darkness !) Dosage used was- 10 mg OD with no documented side efffects Probable mode of action is via increased excitability of cerebellar purkinje cells from K+ channel blockade 4-aminopyridine restores visual ocular motor function in upbeat nystagmus,S Glasauer, M Strupp et al, Jour. Neurol Neurosurg Psychiatry 2005;76:451–453.

31 Electronic methods Device uses infrared sensor guided measurement of eye movements and feeding the same to a phase locked loop / adaptive filters which generates an electric signal which in turn rotate the riley prisms synchronous with the nystagmus and through which the person views the world. In future we might have specs which uses this miniature principle to cancel out the visual effects of pathological nystagmus. Application of adaptive filters to visual testing and treatment in acquired pendular nystagmus, Ryan M. Smith, John S. Stahl, Journal of Rehabilitation, Research & Development,Vol 41,June 2004, Prospects for Treating Acquired Pendular Nystagmus with Servo-Controlled Optics, John Stahl et al, Invest Ophthal Vis Sci, 2000, Apr, 41(5),

32 Prototype electronic device Infrared device Prism assembly Acuity card

33 T & R (Tenotomy & Resuturing) Principle- Operating on the tendon where the Proprioceptive feedback loop for ocular-motor control is located. Method- Surgically detach the muscles from the globe and suture them back to their original insertions without resection or recession Holds lots of promise for CIN where AHP is not an issue There are group of people who don’t believe in and find it contentious Improves NAFX ( eXpanded Nystagmus Acuity Function) - an indicator of target foveation, fastens target acquisition time and also reduce oscillopsia.. Dell'Osso LF, Hertle RW, Williams RW, Jacobs JB. A new surgery for congenital nystagmus: effects of tenotomy on an achiasmatic canine and the role of extraocular proprioception. J AAPOS 1999;3: Hertle RW, Dell’Osso LF, FitzGibbon EJ, Yang D, Mellow SD. Horizontal rectus muscle tenotomy in patients with infantile nystagmus syndrome: a pilot study. J AAPOS. 2004;8:

34 Source - Effects of tenotomy on patients with infantile nystagmus syndrome, Wang, Dell Osso et al, JAAPOS,2006,10:

35 Simple Augmented Tendon Suture ( ATS) No tenotomy is required. 3 cross sword sutures with 6-0 vicryl are placed in the tendon towards the myotendinous junction,not suturing the globe Probable mode of action- ischemia, irritation and scarring which would act through the proprioceptive loop. It causes relaxation of the resting muscle /steady state innervation and puts it on lower portion of length- tension curve. Two hypothetical Nystagmus procedures : Augmented Tenotomy and Reattachment and Augmented tendon suture ( Sans Tenotomy ), Dell’ Osso, J Pediatr Ophthalmol Strabismus, 2009;46:

36 Split Tendon, ATS method As the name suggests you need to do a tendon split along the length and then pass the sutures on either side taking care of the vascular arcades. No concrete evidence has yet been established about this procedure Its efficacy needs to be established and is just a hypothesis in current scenario Two hypothetical Nystagmus procedures : Augmented Tenotomy and Reattachment and Augmented tendon suture ( Sans Tenotomy ), Dell’ Osso, J Pediatr Ophthalmol Strabismus, 2009;46:

37 GENETICS IN NYSTAGMUS

38 GENE THERAPY Applicable in SENSORY DEFICIT NYSTAGMUS secondary to retinal pathologies Applied to the retina to correct genetic deficits that impair vision directly and may facilitate the development of nystagmus E.g- RPE65 gene deficiency in Leber’s Congenital Amaurosis Achromatopsia Moorefields hosp performed recombinant adenovirus vector guided delivery of missing gene in 3 patients Maguire, A. M., Simonelli, F et al. (2008). Safety and efficacy of gene transfer for Leber's congenital amaurosis The New England journal of medicine, 358(21), 2240–2248. Bainbridge, J. W. B., Smith et al. (2008). Effect of gene therapy on visual function in Leber's congenital amaurosis The New England journal of medicine, 358(21), 2231–2239

39 GENETIC ANALYSIS & COUNSELLING Individual cases- History taking and thorough documentation of family tree will help us know the mode of transmission, associated conditions and penetrance. Helpful in CIN- FRMD7 gene mutation, if documented then its known to have better vision, lesser AHP issue and better prognosis Genetic analysis provides scope for research, which might turn a milestone for gene therapy in future Phenotypical characteristics of idiopathic infantile nystagmus with and without mutations in FRMD7, Gottlob I, Shery et al, Brain (2008), 131,

40 SOCIAL ISSUES Need extra help at school Positioning : Front benches of classroom to match AHP which will improve visual acuity, teachers need to adopt bold writing, high contrast boards Extra-curricular activities- Avoid sports requiring fine vision i.e., ball games. Instead swimming can be preferred Carrier guidance - Prefer visually less demanding professions Personality development workshops Helpline / Networking - In India we don’t have any helpline like NN (Nystagmus Network) in Europe In US they have the ANN ( American Nystagmus Network) The main intent of these sites/ networks is to improve the quality of life for all persons and families affected by nystagmus, through organized community support, education and public awareness

41 Thank You


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