Download PDF
Semin Neurol 2007; 27(3): 244-256
DOI: 10.1055/s-2007-979682
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Oculomotor Disorders

Janet C. Rucker1
  • 1Department of Neurological Sciences, Rush University, Chicago, Illinois
Further Information

Publication History

Publication Date:
18 June 2007 (online)

    Permissions and Reprints

ABSTRACT

Ocular misalignment and nystagmus result in the visual symptoms of binocular diplopia and oscillopsia, and are frequently encountered in neurological practice. Correct localization of the underlying problem is the first step to accurate diagnosis, and requires a systematic approach and knowledge of the ocular motor pathways and actions of the extraocular muscles. This article contains three segments: The first outlines the diagnostic approach with attention to fine historical and examination details helpful in localization; the second describes common localizations of diplopia including extraocular muscle, neuromuscular junction, cranial nerve and nuclei, and supranuclear structures with attention to examination features characteristic for each location; and the third describes the types of acquired nystagmus and their treatments.

KEYWORDS

Eye movements - binocular diplopia - oscillopsia - nystagmus

REFERENCES

  • 1 Carpenter R. The visual origins of ocular motility. In: Carpenter R Eye Movements. London; MacMillan Press 1991: 1-10
    Google Scholar
  • 2 Coffeen P, Guyton D L. Monocular diplopia accompanying ordinary refractive errors.  Am J Ophthalmol. 1988;  105 451-459
    PubMedGoogle Scholar
  • 3 Barton J J. “Retinal diplopia” associated with macular wrinkling.  Neurology. 2004;  63 925-927
    PubMedGoogle Scholar
  • 4 De Pool M E, Campbell J P, Broome S O, Guyton D L. The dragged-fovea diplopia syndrome: clinical characteristics, diagnosis, and treatment.  Ophthalmology. 2005;  112 1455-1462
    CrossrefPubMedGoogle Scholar
  • 5 Rucker J C, Tomsak R L. Binocular diplopia: a practical approach.  Neurologist. 2005;  11 98-110
    CrossrefPubMedGoogle Scholar
  • 6 Cremer P D, Halmagyi G M, Aw S T et al.. Semicircular canal plane head impulses detect absent function of individual semicircular canals.  Brain. 1998;  121 699-716
    CrossrefPubMedGoogle Scholar
  • 7 Black R A, Halmagyi G M, Thurtell M J, Todd M J, Curthoys I S. The active head-impulse test in unilateral peripheral vestibulopathy.  Arch Neurol. 2005;  62 290-293
    CrossrefPubMedGoogle Scholar
  • 8 Toth C, McDonald D, Oger J, Brownell K. Acetylcholine receptor antibodies in myasthenia gravis are associated with greater risk of diabetes and thyroid disease.  Acta Neurol Scand. 2006;  114 124-132
    CrossrefPubMedGoogle Scholar
  • 9 Marino M, Barbesino G, Pinchera A et al.. Increased frequency of euthyroid ophthalmopathy in patients with Graves' disease associated with myasthenia gravis.  Thyroid. 2000;  10 799-802
    PubMedGoogle Scholar
  • 10 Nicholson G A, McLeod J G, Griffiths L R. Comparison of diagnostic tests in myasthenia gravis.  Clin Exp Neurol. 1983;  19 45-49
    PubMedGoogle Scholar
  • 11 Beekman R, Kuks J B, Oosterhuis H J. Myasthenia gravis: diagnosis and follow-up of 100 consecutive patients.  J Neurol. 1997;  244 112-118
    PubMedGoogle Scholar
  • 12 Ing E B, Ing S Y, Ing T, Ramocki J A. The complication rate of edrophonium testing for suspected myasthenia gravis.  Can J Ophthalmol. 2000;  35 141-144 , discussion 145
    PubMedGoogle Scholar
  • 13 Kupersmith M J, Latkany R, Homel P. Development of generalized disease at 2 years in patients with ocular myasthenia gravis.  Arch Neurol. 2003;  60 243-248
    CrossrefPubMedGoogle Scholar
  • 14 Ellis F D, Hoyt C S, Ellis F J, Jeffery A R, Sondhi N. Extraocular muscle responses to orbital cooling (ice test) for ocular myasthenia gravis diagnosis.  J AAPOS. 2000;  4 271-281
    PubMedGoogle Scholar
  • 15 Benatar M. A systematic review of diagnostic studies in myasthenia gravis.  Neuromuscul Disord. 2006;  16 459-467
    CrossrefPubMedGoogle Scholar
  • 16 Odel J G, Winterkorn J M, Behrens M M. The sleep test for myasthenia gravis: a safe alternative to Tensilon.  J Clin Neuroophthalmol. 1991;  11 288-292
    PubMedGoogle Scholar
  • 17 Costa J, Evangelista T, Conceicao I, de Carvalho M. Repetitive nerve stimulation in myasthenia gravis: relative sensitivity of different muscles.  Clin Neurophysiol. 2004;  115 2776-2782
    CrossrefPubMedGoogle Scholar
  • 18 Padua L, Stalberg E, LoMonaco M, Evoli A, Batocchi A, Tonali P. SFEMG in ocular myasthenia gravis diagnosis.  Clin Neurophysiol. 2000;  111 1203-1207
    CrossrefPubMedGoogle Scholar
  • 19 Bennett D L, Mills K R, Riordan-Eva P, Barnes P R, Rose M R. Anti-MuSK antibodies in a case of ocular myasthenia gravis.  J Neurol Neurosurg Psychiatry. 2006;  77 564-565
    CrossrefPubMedGoogle Scholar
  • 20 Hanisch F, Eger K, Zierz S. MuSK-antibody positive pure ocular myasthenia gravis.  J Neurol. 2006;  253 659-660
    CrossrefPubMedGoogle Scholar
  • 21 Kupersmith M J, Ying G. Ocular motor dysfunction and ptosis in ocular myasthenia gravis: effects of treatment.  Br J Ophthalmol. 2005;  89 1330-1334
    CrossrefPubMedGoogle Scholar
  • 22 Carrasco J R, Savino P J, Bilyk J R. Primary aberrant oculomotor nerve regeneration from a posterior communicating artery aneurysm.  Arch Ophthalmol. 2002;  120 663-665
    PubMedGoogle Scholar
  • 23 Keane J R. Bilateral involvement of a single cranial nerve: analysis of 578 cases.  Neurology. 2005;  65 950-952
    CrossrefPubMedGoogle Scholar
  • 24 Feinberg A S, Newman N J. Schwannoma in patients with isolated unilateral trochlear nerve palsy.  Am J Ophthalmol. 1999;  127 183-188
    CrossrefPubMedGoogle Scholar
  • 25 Hanson R A, Ghosh S, Gonzalez-Gomez I, Levy M L, Gilles F H. Abducens length and vulnerability?.  Neurology. 2004;  62 33-36
    CrossrefPubMedGoogle Scholar
  • 26 Dhaliwal A, West A L, Trobe J D, Musch D C. Third, fourth, and sixth cranial nerve palsies following closed head injury.  J Neuroophthalmol. 2006;  26 4-10
    CrossrefPubMedGoogle Scholar
  • 27 Rabadi M H, Beltmann M A. Midbrain infarction presenting isolated medial rectus nuclear palsy.  Am J Med. 2005;  118 836-837
    CrossrefPubMedGoogle Scholar
  • 28 Kwon J H, Kwon S U, Ahn H S, Sung K B, Kim J S. Isolated superior rectus palsy due to contralateral midbrain infarction.  Arch Neurol. 2003;  60 1633-1635
    CrossrefPubMedGoogle Scholar
  • 29 Miller N R, Biousse V, Hwang T, Patel S, Newman N J, Zee D S. Isolated acquired unilateral horizontal gaze paresis from a putative lesion of the abducens nucleus.  J Neuroophthalmol. 2002;  22 204-207
    PubMedGoogle Scholar
  • 30 Gamlin P D, Gnadt J W, Mays L E. Lidocaine-induced unilateral internuclear ophthalmoplegia: effects on convergence and conjugate eye movements.  J Neurophysiol. 1989;  62 82-95
    PubMedGoogle Scholar
  • 31 Frohman T C, Frohman E M, O'Suilleabhain P et al.. Accuracy of clinical detection of INO in MS: corroboration with quantitative infrared oculography.  Neurology. 2003;  61 848-850
    CrossrefPubMedGoogle Scholar
  • 32 Kim J S. Internuclear ophthalmoplegia as an isolated or predominant symptom of brainstem infarction.  Neurology. 2004;  62 1491-1496
    PubMedGoogle Scholar
  • 33 Choi K D, Jung D S, Kim J S. Specificity of “peering at the tip of the nose” for a diagnosis of thalamic hemorrhage.  Arch Neurol. 2004;  61 417-422
    CrossrefPubMedGoogle Scholar
  • 34 Messe S R, Cucchiara B L. Wrong-way eyes with thalamic hemorrhage.  Neurology. 2003;  60 1524
    PubMedGoogle Scholar
  • 35 Leigh R J, Thurston S E, Tomsak R L, Grossman G E, Lanska D J. Effect of monocular visual loss upon stability of gaze.  Invest Ophthalmol Vis Sci. 1989;  30 288-292
    PubMedGoogle Scholar
  • 36 Averbuch-Heller L, Tusa R J, Fuhry L et al.. A double-blind controlled study of gabapentin and baclofen as treatment for acquired nystagmus.  Ann Neurol. 1997;  41 818-825
    CrossrefPubMedGoogle Scholar
  • 37 Shery T, Proudlock F A, Sarvananthan N, McLean R J, Gottlob I. The effects of gabapentin and memantine in acquired and congenital nystagmus: a retrospective study.  Br J Ophthalmol. 2006;  90 839-843
    CrossrefPubMedGoogle Scholar
  • 38 Halmagyi G M, Leigh R J. Upbeat about downbeat nystagmus.  Neurology. 2004;  63 606-607
    PubMedGoogle Scholar
  • 39 Strupp M, Schuler O, Krafczyk S et al.. Treatment of downbeat nystagmus with 3,4-diaminopyridine: a placebo-controlled study.  Neurology. 2003;  61 165-170
    CrossrefPubMedGoogle Scholar
  • 40 Kalla R, Glasauer S, Schautzer F et al.. 4-aminopyridine improves downbeat nystagmus, smooth pursuit, and VOR gain.  Neurology. 2004;  62 1228-1229
    PubMedGoogle Scholar
  • 41 Cohen B, Helwig D, Raphan T. Baclofen and velocity storage: a model of the effects of the drug on the vestibulo-ocular reflex in the rhesus monkey.  J Physiol. 1987;  393 703-725
    CrossrefPubMedGoogle Scholar
  • 42 Zee D S, Robinson D A. A hypothetical explanation of saccadic oscillations.  Ann Neurol. 1979;  5 405-414
    CrossrefPubMedGoogle Scholar
  • 43 Kaneko C R. Effect of ibotenic acid lesions of the omnipause neurons on saccadic eye movements in rhesus macaques.  J Neurophysiol. 1996;  75 2229-2242
    PubMedGoogle Scholar

Janet C RuckerM.D. 

Assistant Professor of Neurology and Ophthalmology, Department of Neurological Sciences, Rush University

1725 West Harrison Street, Suite 1106, Chicago, IL 60612