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NYSTAGMUS

NYSTAGMUS. M. SOLTAN SANJARI, M.D. RASSOUL AKRAM HOSPITAL I. U. M. S. NYSTAGMUS. Nystagmus is a rhythmic oscilation of one or both eyes about one or more axes . NYSTAGMUS. Ethiology 1. Secondary to visual deficit 2. Secondary to intracranial lesions and drug toxicit

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NYSTAGMUS

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  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. NYSTAGMUS • Ethiology 1. Secondary to visual deficit 2. Secondary to intracranial lesions and drug toxicit 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. NYSTAGMUS • Classification: 1. Clinical appearance 2. The waveform as revealed by ENG 3. Etiological grounds

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

  7. NYSTAGMUS • Terminology: • Manifest, Latent, Latent Component • Gaze-evoked, Gaze-paretic, Gaze-dependent • Asymmetry and Dissociated

  8. NYSTAGMUS • Examination: • Family History • Time of onset • Ocular Examination • ERG, PVEP • ENG

  9. 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.

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

  11. Voluntary

  12. Vestibular

  13. OKN

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

  15. 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

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

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

  18. Head posture

  19. Wandering eye

  20. 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 spasmusnutans, particularly if there is associated head nodding)

  21. 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, …………….

  22. 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

  23. NEUROLOGICAL AND NEUROMUSCULAR NYSTAGMUS • Acquired PendularNystagmus • High frequency, Low frequency, Horizontal, Vertical, Circular, Elliptical, Unilateral, Bilateral • Demyelinating, Oculopalatalmyocolonus, Drugs, Glue stiffing, Late low vision, Neurodegeneratives, ChiasmalGlioma, Craniopharyngioma • Head thrust

  24. Acquired Pendular Nystagmus

  25. Acquired Pendular Nystagmus

  26. Acquired Pendular Nystagmus

  27. Acquired Pendular Nystagmus

  28. See-saw Nystagmus

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

  30. See-saw Nystagmus

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

  32. 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

  33. Down beaten and horizontal Nystagmus MS

  34. Upbeat Nystagmus

  35. Upbeat Nystagmus

  36. Downbeat Nystagmus

  37. Downbeat Nystagmus

  38. Downbeat Nystagmus

  39. 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.

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

  41. 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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