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NYSTAGMUS M. SOLTAN SANJARI, M.D. RASSOUL AKRAM HOSPITAL I. U. M. S.

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Presentation on theme: "NYSTAGMUS M. SOLTAN SANJARI, M.D. RASSOUL AKRAM HOSPITAL I. U. M. S."— Presentation transcript:

1 NYSTAGMUS M. SOLTAN SANJARI, M.D. RASSOUL AKRAM HOSPITAL I. U. M. S.

2 NYSTAGMUS Nystagmus is a rhythmic oscilation of one or both eyes about one or more axes.

3 NYSTAGMUSEthiology 1. Secondary to visual deficit 1. Secondary to visual deficit 2. Secondary to intracranial 2. Secondary to intracranial lesions and drug toxicit lesions and drug toxicit 3. Congenital benign idiopathic 3. Congenital benign idiopathic

4 NYSTAGMUS Mechanisms : 1. The nystagmus intensity is too high, or vision is too poor for complete suppression 2. Concomitant disorder of the smooth pursuit system 3. The fixation and smooth pursuit systems are themselves at fault

5 NYSTAGMUSClassification: 1. Clinical appearance 2. The waveform as revealed by ENG 3. Etiological grounds

6 NYSTAGMUS Terminology : Congenital 1.Sensory Defect Nystagmus (SDN) 1.Sensory Defect Nystagmus (SDN) 2. Congenital Idiopathic Nystagmus (CIN) 2. Congenital Idiopathic Nystagmus (CIN) Jerk and Pendular Nystagmus Axes of Oscillations Direction Null Zone Amplitude, Frequency, Intensity

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8 NYSTAGMUSTerminology: Manifest, Latent, Latent Component Gaze-evoked, Gaze-paretic, Gaze- dependent Asymmetry and Dissociated

9 NYSTAGMUSExamination: Family History Time of onset Ocular Examination ERG, PVEP ENG

10 NYSTAGMUS ENG 1. Jerk N. with an accelerating slow phase 2. Jerk N. with an decelerating slow phase 3. Constant velocity or linear slow phase 4. Pendular N.

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12 NYSTAGMUS Physiologic Nystagmus 1. OKN 1. OKN 2. Induced Vestibular N. 2. Induced Vestibular N. 3. End Point N. 3. End Point N. 4. Voluntary N. 4. Voluntary N.

13 Voluntary

14 Vestibular

15 OKN

16 NYSTAGMUS Latent Nystagmus (LN): Most common Most common Before 6 mo. Before 6 mo. Horizontal, Jerk, Conjugate Horizontal, Jerk, Conjugate Wave form Wave form Primary position, Add., Abd. Head turn Primary position, Add., Abd. Head turn Genetic factor Genetic factor

17 MLN plus Alternating fixation strabismus fast phases always in the direction of the fixating eye misdiagnosed as having CN, because the nystagmus is present with both eye opens

18 NYSTAGMUS SDN, and CIN: Sensory Defect ? Incidence 9/1 Horizontal, Circumrotatory in early infancy Null Zone ( 1/3 is eccentric ) IntensityInheritance Optokinetic Response Wave form Visual Performance Oscillopsia

19 Congenital nystagmus Characteristics: Binocular Binocular Similar amplitude in both eyes Similar amplitude in both eyes Usually uniplanar (horizontal) in all gazes Usually uniplanar (horizontal) in all gazes Diminished by convergence Diminished by convergence Increased by fixation attempt Increased by fixation attempt Superimposition of latent component Superimposition of latent component Abolished in sleep Abolished in sleep Head oscillations Head oscillations

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21 Head posture

22 Wandering eye

23 Sensory Defect Nystagmus Consequent to bilateral visual loss cannot be distinguished from CIN in a patient with coexisting primary visual abnormalities. Monocular visual loss may produce monocular nystagmus, usually vertical, at any age from birth through adult life (it may mimic spasmus nutans, particularly if there is associated head nodding)

24 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Gaze Paretic Nystagmus The most common form of N. after infancy Mismatch between gaze-holding circuit and EOM dynamics Head thrusts Cerebellar Disease, Drugs, Myasthenia, Vestibular Disease, …………….

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27 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Rebound Nystagmus Usually with GPN Unilateral or bilateral Not dependent to vision No change with illumination Flocculus tumors Chronic vestibulocerebellar disease

28 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Acquired Pendular Nystagmus High frequency, Low frequency, Horizontal, Vertical, Circular, Elliptical, Unilateral, Bilateral Demyelinating, Oculopalatal myocolonus, Drugs, Glue stiffing, Late low vision, Neurodegeneratives, Chiasmal Glioma, Craniopharyngioma Head thrust Head thrust

29 Acquired Pendular Nystagmus

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33 See-saw Nystagmus

34 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS See-saw Nystagmus Elevates and Intorts Depresses and Extorts Bitemporal hemianopia (Maddox 1914) Parasellar and Chiasmal Lesions Damage to the pathway of zonaincerta to the interstitial nucleus of Cajal (Thalamic lesion) Congenital and Idiopathic

35 See-saw Nystagmus

36 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Vestibular Nystagmus Peripheral and Central Dizziness, Vertigo, Oscillopsia Central adaptation Recovery Nystagmus Vestibular Neuritis Positional Nystagmus Benign paroxysmal Positional Vertigo Benign paroxysmal Positional Vertigo

37 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Downbeat Nystagmus  Lateral gaze Craniocervical Abnormality, Cerebellar Degeneration,  ICP, Drugs, Nutritional Deficiencies Upbeat Nystagmus Pontomedulary Junction, Midbrain, Vermis Lesions Organophosphate Poisoning

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39 Down beaten and horizontal Nystagmus MS

40 Upbeat Nystagmus

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42 Downbeat Nystagmus

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47 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Torsional Nystagmus Sometimes only detect by ophthalmoscopy Midpontine, Central vestibular connections Lesions Part of SSN, Peripheral vestibular Nystagmus, SDN/CIN, LN.

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49 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Abduction Nystagmus INO, Myasthenia, After strabismus surgery INO, Myasthenia, After strabismus surgery Periodic Alternating Nystagmus Acquired. Part of SDN/CIN Acquired. Part of SDN/CIN 90 Second each cycle 90 Second each cycle Ping-Pong Gaze Ping-Pong Gaze Lower brain stem, Cerebellar, Anomalies Lower brain stem, Cerebellar, Anomalies Drugs, Chronic alcoholism. Drugs, Chronic alcoholism. Baclofen Sometimes useful Baclofen Sometimes useful

50 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Epileptic Nystagmus Rare but may be the only sign of seizure Usually Horizontal Lid Nystagmus Usually associated with vertical nystagmus Icthal phenomenon, Posterior fossa lesions,

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52 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Convergence-Retraction Nystagmus Posterior commissure Lesions: Hemorrhage, Infarct, Demyelinating, Hydrocephalus. Posterior commissure Lesions: Hemorrhage, Infarct, Demyelinating, Hydrocephalus. Downward OKN  CRN Downward OKN  CRN

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54 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Head Oscilations (Head shaking - Head nodding) 1. SDN/CIN 1. SDN/CIN 2. Bobble-Head Doll Syndrome 2. Bobble-Head Doll Syndrome 3. Spasmus Nutans 3. Spasmus Nutans

55 NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS Spasmus Nutans (Nodding Spasm) Triad: 1. Asymetric APN 2.Head Nodding 2.Head Nodding 3. Head Tilt or Turn 3. Head Tilt or Turn 4mo. - 2 years improved before 5 years Poor Family ERGNeuroimaging

56 Management Management

57 Management Aims Vision improvement Oscillopsia Improvement Head posture elimination Treatment of Strabismus

58 Non-Surgical Management Treatment of amblyopia Refractive errors correction Minus therapy Partial field occlusion Contact lenses Prisms Head posture Head posture Vision Vision

59 Non-Surgical Management Systemic medications Baclofen ( CN, See-saw, PAN ) Baclofen ( CN, See-saw, PAN ) Clonazepam ( Downbeaen ) Clonazepam ( Downbeaen ) Carbamazepine ( SO myokymia ) Carbamazepine ( SO myokymia ) Botulinum toxin ( Diplopia, ptosis, filamentary keratopathy,... ) ( Diplopia, ptosis, filamentary keratopathy,... )

60 Surgical Treatment  To eliminate a compensatory head posture  To decrease nystagmus amplitude, or for both reasons  strabismus surgery may convert manifest- latent nystagmus to latent nystagmus, causing improvement of binocular visual acuity

61 Head Turn  “the eyes should always be shifted in the direction of the anomalous head posture”  Head turn or tilt of more than 15 to 20 is of cosmetic or functional significance  Ascertain beyond doubt by repeated examinations that the direction of the null zone and thus of the head turn is consistent

62 Head Turn Kestenbaum-Anderson Procedure Posterior Fixation Suture Modified Anderson Procedure Modification for coexisting heterotropia

63 Chin-Up or Down Large recession of vertical muscles Think about lids position Think about lids position Vertical R & R

64 Head Tilt Horizontal or vertical muscles displacement For head tilt to right: Transposing right SR nasally and right IR temporally and opposite in left eye Transposing right SR nasally and right IR temporally and opposite in left eye or or Supraplacement of right LR and infraplacement Supraplacement of right LR and infraplacement of right MR of right MR

65 To decrease nystagmus amplitude To decrease nystagmus amplitude Large recession of 4 horizontal muscles Disinsertion and reinsertion of 4 horizontal muscles (Hertel)

66 THANK YOU


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