Nystagmus

Pembimbing: dr. Donny H

Hamid SpS
Disusun oleh: Nadira Danata
110201188

Definition
An involuntary repetitive rhythmic
oscillations of one or both eyes in
one or all of the visual field . Can be
either congenital or acquired , which
is about the whole age.

Epidemiology
24 per 10,000 population
18 years: 16.6 per 10,000
population albinism
Adult: 26.5 per 10,000
neurological disease
Caucasian > Asian
No evidance gap between male and
female

Eye Muscle

Vestibular System

Vestibular System

Connection underlying VOR

Others Central Vestibular

Pathway

Physiology
Three mechanisms are involved in maintaining
foveal centration of an object of interest:
- fixation of primary position
:
a) detect retinal image drift of foveating image
b) suppress unwanted saccadic movement
- the vestibulo-ocular reflex
- the neural integrator :
a)required contraction of the extraocular muscle
b)gaze holding network signal
c)cerebellum, ascending vestibular pathway,
oculomotor
nuclei

Physiologically Induced
Nystagmus
Optokinetic nystagmus: involuntary,
conjugate, jerk nystagmus that is
seen when a person gazes into a
large moving field. The oscillations,
which are in the plane of the moving
fields.
Consist of smooth pursuit and
saccadic.

Physiologically Induced
Nystagmus
Vestibular nystagmus: occurs during
self-rotation. It occurs due to the
signals sent by the vestibular
labyrinth to the vestibular nuclei and
the cerebellum. Induced by irrigating
ears.
End-point nystagmus: a small
amplitude conjugate jerk nystagmus
on far eccentric gaze.

Congenital/ Infantile
Nystagmus
CN
-

usually recognized in first few months of life

May have good vision or poor vision
Slow phase velocity increase exponentally
Conjugate, horizontal, and jerky
My occur without any ocular or central nervus system
anomalies, may be associated with albinism, optic
nerves hypoplasia, and congenital cataracts.
- Near normal vision if they have develop foveation
period
- Amplified by attempted fixation
- Dampened by convergence and darkness and certain
gaze angle

 MLN
- Usually appears within first few months of life
- the slow phase velocity decreases or remains
the same
- associated with strabismus, albinism, optic
nerve hypoplasia, congenital cataract
- frequently in patient with congenital uniocular
loss/ visual deprivation

Acquired Nystagmus

Vestibular nystagmus
Down beating nystagmus (DBN)
Torsional nystagmus
Periodic alternation nystagmus
See-saw nystagmus
Gaze evoked nystagmus
INO

Vestibular nystagmus
As result from disease affecting the
vestibular organ in the inner ear
Usually associated with vertigo

PERIPHERAL VS. CENTRAL

VESTIBULAR NYSTAGMUS
Peripheral

Central

Unidirectional, fast phase

opposite the lesion; Usually
horizontal with torsion

Unidirectional/ bidirectional;
purely vertical or torsional
nystagmus

Dampened by visual fixation

Not dampened by visual

fixation

Tinitus, deafness (+)

Tinitus, deafness (-)

Severe vertigo

Non or mild vertigo

Commonly peripheral
vestibular organ dysfunction:
labyrynthitis, menieres

Etiologies commonly vascular,

demyelination, pharmacologic,
toxic

Days to weeks duration

Often chronic

DBN
Arnold Chiari Malformation, Lesions
of the vestibulo-cerebellum
(flocculus, paraflocculus, nodulus,
and uvula), MLF, Ventral tegmentum,
the anterior vernis of cerebellum

UBN
1st type: large amplitude increases
in intensity with upward gaze
anterior vermis of cerebellum
2nd type: small amplitude decreases
in intensity with upward gaze,
increases intensity in downward gaze
medulla

Torsional nystagmus
Lession of the anterior and posterior
SCC on the same side (lateral
medullary synd)
Fast phase directed away from the
side of lession
Accentuated by stimulating otolith

Periodic Alternating
Nystagmus
Distruption of the vestibulo-ocular at
the pontomedulallary junction. Often
linked to cerebellar disease
Conjugate, horizontal jerk
Fast phase beating 1-2 minutes,
neutral phase 10-20 secs and repeat

See-saw Nystagmus
Sellar and parasellar lessions (note
that is rare form of pendular
nystagmus in which the torsional
components are disjunctive one
eyerises and intors while the other
falls and exorts);

Abducting Nystagmus in
Internuclear Ophtalmoplegia
(INO)

Lession affecting the MLF, contralateral

to MLF lession
Unilateral ischemia
Bilateral multiple sclerosis
An adduction weakness on conjugate
movements and a jerk nystagmus of
the abducting eye are the classic ocular
motor sign (dissociated nystagmus).

 Eyes no longer move as one and nystagmus

is present in one eye but not the other.
In unilateral MLF lesions the eye fails to
adduct towards the affected side.
multiple sclerosis, brainstem infarction,
haemorrhage, trauma, and drug toxicity
(phenytoin).

Acquired Pendular
Nystagmus
can occur in any plane, it can be
monocular or have a greater intensity in
one eye and typically remains pendular
in all directions of gaze.
wide range of brainstem and cerebellar
disease including several disorders of
myelin, and with drug toxicities.
In multiple sclerosis

Gaze-evoked Nystagmus
side-effect of drugs, including
sedative, anti-convulsant and
alcohol, as well as cerebellar disease.
elicited when the patient attempts to
maintain an eccentric eye position.

Gaze-evoked Nystagmus
The oscillations are jerky, with a centripetal
decreasing velocity exponential slow phase
take the eyes away from the desire eye
position, followed by a corrective fast phase.
A failure of the step (or tonic) eye position
command from the gaze-holding network (the
neural integrator). After the eyes are returned
to the primary position, a short-lived reflex
nystagmus with quick phases opposite to the
direction of the previous eccentric gaze
oscillation can typically be seen in vestibulocerebellar diseases.

Examination of Nystagmus
checking the movement of the eyeball
the patient was told to continue to glance
in one direction during 5 or 6 seconds
Nystagmoid movements of the eyes are
present in many people at extremes
gaze.
Nystagmus present with the eyes
deviated less than 30 from the midline is
abnormal.

Examination of Nystagmus
Where the nystagmus there should be checked:

Type of movement: pendular/ jerk nystagmus

Planes: horizontal, vertical, or a mixture rotatoar.
Frequency: (fast or slow)
The amplitude (large or small, rough or smooth)
Directions; the direction of the fast component.
Degree:

Grade I: nystagmus appears when glancing towards

the fast component;
Grade II: also there if looking ahead;
Grade III: nystagmus also occur when glance towards
the slow component.
Duration: permanent or pass

 Horizontal/ horizontal-rotatoar
Vetibular nytagmus (peripheral)
Vertical nystagmus brain stem
(mesensephalon and m.o)
Horizontal pons tegmentum and
mesensephalon
Horizontal-rotatoar/ rotatoar m.o

Retinal/ ocular nystagmus

Physiological: optokinetic nystagmus
Pathological: devective vision,
fixation is impaired
Rapid
Pendular
Increasing when looking to sides
Persistent through lifetime

Vestibular nystagmus
Physiological

 Pathological
- slow phase to the lesion, fast phase
to normal side, setle simultaneously
- tinitus, hearing loss, vertigo
- menieres disease, vestibular
neuronitis, vascular damage

Positional nystagmus
Dix-hallpike
maneuver

Diagnosis BPPV of
the posterior canal
Delay nystagmus
with rotatory
component
Repeated
fatigues

Positional nystagmus
Pagnini-McClure
maneuver

Lateral canal type

Central Nervus System

Damage to the central
vestibular connection
in the VN and brain
stem
Horizontal, vertical,
rotatory, dissociated
Fast phase ditermined
by direction of gaze
Vertigo seldom
Sips of other nuclear
in brainstem

Vascular dis,
neoplasm,
demyelination,
alcohol intoxication,
drug tixocity
Cerebellar dis fast
phase to the
cerebellar damage
Posterior fossa
positional nystagmus

Differences between Peripheral

and Central Nystagmus
Peripheral Nystagmus

Central Nystagmus

Vertigo

Heavy

Light

Latency

Yes

No

Habituation

Yes

No

Direction

Nystagmus contralateral lesions Nystagmus towards lesion

Duration

Fatigue

Planes

Horizontal/ horizontal rotatoar Horizontal,

Persistent
vertical,

rotatoar, multi-directional
Head position

Increase with the change of not truly evoked by the

head position

positional maneuver

 Neuro Imaging (MRI)

Electronystamograph

Treatment and medication

Stop medications that induced
nystagmus
Removing the etilogy
Contact lenses