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NystagmusGauri S. Shrestha, M.Optom, FIACLE
What is Nystagmus? Involuntary and repetitive oscillatory movement  of one or both eyes May be physiological or patholog...
Depth of Field Reduced by nystagmus These patients may be prone to tripping or  clumsiness. Co-ordination is usually ad...
Description Position (Primary or gaze-related) Frequency (Rapid or slow) Null zone:     Nystagmus is minimal in this f...
Representation                  Jerky Nystagmus                  Rt. Beating                  Lt. beating                 ...
Diagrammatic depiction of Nystagmus                   Gauri S Shrestha, M.optom, FIACLE      Horizontal Nystagmus
Null Zone & Neutral Zone Null Zone    The field of gaze in which nystagmus intensity is     minimal    The eye position...
Incidence Nystagmus affects about one in a thousand people. One survey identified one in every 670 children by  the age ...
What Causes Nystagmus? May be inherited or result from a sensory problem      some cases occur for no known reason It c...
What Should We Know? Refractive error Correction    Limitations Vision often varies during the day      affected by em...
Classification             Gauri S Shrestha, M.optom, FIACLE
Non-Physiological NystagmusBased on Appearance of waveform 1. Jerk Nystagmus     Well-defined slow and      fast phases 2...
Physiological nystagmus... Optokinetic nystagmus (OKN)    Jerky nystagmus induced by     moving patterned targets across...
Physiological nystagmus End point nystagmus      Fine jerk nystagmus extreme gaze position Fixation nystagmus - fine os...
 Caloric test    If hot water is irrigated into right ear – patient will     develop right jerk nystagmus.    Cold wate...
Classification             Gauri S Shrestha, M.optom, FIACLE
Congenital nystagmus Infrequently observed at birth. Onset is usually during the first 3-4 months of life  but may emerg...
Congenital Nystagmus Latent nystagmus     Jerky horizontal nystagmus seen when light stimulus      to one or other eye d...
Latent nystagmus…           Gauri S Shrestha, M.optom, FIACLE
Manifest congenital nystagmus Nystagmus evoked when both eyes are open. Amplitude doesnot change on covering one eye.  ...
Sensory defect nystagmus Basic cause is the inadequate image formation on  the fovea      As a result of inadequate ante...
Motor defect nystagmus Primary defect is in the efferent mechanism. No ocular abnormalities are present. Amplitude & fr...
Congenital Nystagmus Pendular Nystagmus    Can be found in patients with known foveal     disorder       Macular Scarri...
 Latent manifest nystagmus     Occurs in children with decreased vision in one eye      where the poorly seeing eye beha...
Nystagmus blockage syndrome(NBS) Congenital nystagmus dampens  with convergence or adduction. Demonstrates an esotropia ...
Periodic alternating nystagmus Unusual form of congenital motor jerk nystagmus Patient starts with a jerk nystagmus in o...
Characteristics of CongenitalNystagmus Binocular Similar amplitude in both eyes Usually uniplanar (horizontal) in all g...
Acquired : Spasmus nutans combination of nystagmus, involuntary head nodding and  abnormal head posture. Intermittent rap...
Acquired Acquired pendular nystagmus - result of cerebellar  or brainstem lesions. equal amplitude of  nystagmus in all g...
Acquired Gaze evoked nystagmus -an inability to maintain the eyes  in a lateral or vertical gaze position. The eyes drift...
See-saw nystagmus Unusual & dramatic type. Has both vertical & Torsional    components.   Eyes make alternating    move...
 Downbeat nystagmus: jerky vertical nystagmus  seen with increased amplitude on downgaze. The  eyes drift up and beat dow...
Downbeat nystagmus          Gauri S Shrestha, M.optom, FIACLE
Upbeat nystagmus           Gauri S Shrestha, M.optom, FIACLE
Nystagmus Management Neurological Work-up and appropriate  medical treatment      Refer if necessary Provide Best Corre...
How Can You Utilize Null Point? Locate with version (ocular motility) testing Use of Prisms:    Base-Out: if convergenc...
Gauri S Shrestha, M.optom, FIACLE
Gauri S Shrestha, M.optom, FIACLE
Gauri S Shrestha, M.optom, FIACLE
Near Work With Nystagmus The angle of vision is important.    Null point. Adopt a head posture Small print.    Visual ...
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Nystagmus

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Nystagmus

  1. 1. NystagmusGauri S. Shrestha, M.Optom, FIACLE
  2. 2. What is Nystagmus? Involuntary and repetitive oscillatory movement of one or both eyes May be physiological or pathological or idiopathic May be early onset or later onset Often seriously reduces vision Gauri S Shrestha, M.optom, FIACLE
  3. 3. Depth of Field Reduced by nystagmus These patients may be prone to tripping or clumsiness. Co-ordination is usually adequate for most tasks, but nystagmus patients are unlikely to excel at sports needing good hand to eye co-ordination Nystagmus is actually a sign not the diagnosis Gauri S Shrestha, M.optom, FIACLE
  4. 4. Description Position (Primary or gaze-related) Frequency (Rapid or slow) Null zone:  Nystagmus is minimal in this field of gaze (this may be left or right or on convergence Direction  May be horizontal, vertical or rotational (Described by the direction of fast phase) Waveform (Jerk or pendular) Amplitude (How far the eye moves) Gauri S Shrestha, M.optom, FIACLE
  5. 5. Representation Jerky Nystagmus Rt. Beating Lt. beating Pendular Intense jerk Nystagmus o No Nystagmus Gauri S Shrestha, M.optom, FIACLE
  6. 6. Diagrammatic depiction of Nystagmus Gauri S Shrestha, M.optom, FIACLE Horizontal Nystagmus
  7. 7. Null Zone & Neutral Zone Null Zone  The field of gaze in which nystagmus intensity is minimal  The eye position in which a reversal of direction of jerk nystagmus occurs and in which no nystagmus  The null and neutral zones usually overlap; however, several cases have been recorded where they do not. Gauri S Shrestha, M.optom, FIACLE
  8. 8. Incidence Nystagmus affects about one in a thousand people. One survey identified one in every 670 children by the age of two as having nystagmus. Gauri S Shrestha, M.optom, FIACLE
  9. 9. What Causes Nystagmus? May be inherited or result from a sensory problem  some cases occur for no known reason It can also develop in later life, sometimes as a result of an accident or a range of illnesses, especially those affecting the motor system. Gauri S Shrestha, M.optom, FIACLE
  10. 10. What Should We Know? Refractive error Correction  Limitations Vision often varies during the day  affected by emotional/physical factors such as stress, tiredness, nervousness or unfamiliar surroundings. Balance  Poor depth perception, which can make it difficult to go up and down stairs. Gauri S Shrestha, M.optom, FIACLE
  11. 11. Classification Gauri S Shrestha, M.optom, FIACLE
  12. 12. Non-Physiological NystagmusBased on Appearance of waveform 1. Jerk Nystagmus  Well-defined slow and fast phases 2. Pendular Nystagmus  No defined fast phase (pendulum movement) Gauri S Shrestha, M.optom, FIACLE
  13. 13. Physiological nystagmus... Optokinetic nystagmus (OKN)  Jerky nystagmus induced by moving patterned targets across the visual field.  Slow phase along the direction of the moving patterns, followed by a fast phase in opposite direction.  Also called railroad nystagmus.  Clinical significance in detecting visual acuity. Gauri S Shrestha, M.optom, FIACLE
  14. 14. Physiological nystagmus End point nystagmus  Fine jerk nystagmus extreme gaze position Fixation nystagmus - fine oscilllatory movements during the maintenance of steady fixation Caloric nystagmus  Jerk nystagmus caused by altered input from the vestibular nuclei to the horizontal gaze centers.  Nystagmus induced by caloric test. Gauri S Shrestha, M.optom, FIACLE
  15. 15.  Caloric test  If hot water is irrigated into right ear – patient will develop right jerk nystagmus.  Cold water into right ear – left jerk nystagmus  COWS (cold – opposite, warm – same) If both ears are stimulated for  Cold water – upbeat jerk nystagmus  Warm water – downbeat jerk nystagmus Gauri S Shrestha, M.optom, FIACLE
  16. 16. Classification Gauri S Shrestha, M.optom, FIACLE
  17. 17. Congenital nystagmus Infrequently observed at birth. Onset is usually during the first 3-4 months of life but may emerge as late as the teens. Prevalence is 1 in 6550. (Hemmes in 1927). Compensatory head nodding develops at the age of 20 years. Gauri S Shrestha, M.optom, FIACLE
  18. 18. Congenital Nystagmus Latent nystagmus  Jerky horizontal nystagmus seen when light stimulus to one or other eye diminished.  Involuntary rhythmical oscillation of both eyes with fast phase to the fixing eye  Latent nystagmus applies to patients with binocular single vision Gauri S Shrestha, M.optom, FIACLE
  19. 19. Latent nystagmus… Gauri S Shrestha, M.optom, FIACLE
  20. 20. Manifest congenital nystagmus Nystagmus evoked when both eyes are open. Amplitude doesnot change on covering one eye.  Sensory defect nystagmus.  Motor defect nystagmus. Gauri S Shrestha, M.optom, FIACLE
  21. 21. Sensory defect nystagmus Basic cause is the inadequate image formation on the fovea  As a result of inadequate anterior visual pathway disease. Inadequate image formation interferes with the oculomotor control of fixation mechanism. Always bilateral & horizontal. Often is of pendular type  Assumes jerky character in extreme position of gaze. Gauri S Shrestha, M.optom, FIACLE
  22. 22. Motor defect nystagmus Primary defect is in the efferent mechanism. No ocular abnormalities are present. Amplitude & frequency may decrease or nystagmus may disappear completely in one position of gaze (null point / neutral zone).  Visual acuity may improve at the null point / neutral zone. Patient may assume anomalous head posture to  To assume null point.  To improve visual acuity. Gauri S Shrestha, M.optom, FIACLE
  23. 23. Congenital Nystagmus Pendular Nystagmus  Can be found in patients with known foveal disorder  Macular Scarring, Macular Hypoplasia, Optic Nerve Hypoplasia Congenital idiopathic nystagmus  Bilateral, horizontal and jerky with the fast phase to the right on right gaze and vice versa.  There is null point between the two positions and convergence with improved VA Gauri S Shrestha, M.optom, FIACLE
  24. 24.  Latent manifest nystagmus  Occurs in children with decreased vision in one eye where the poorly seeing eye behaves as an occluded eye.  May be due to blindness in one eye or by deep suppression due to strabismus. Gauri S Shrestha, M.optom, FIACLE
  25. 25. Nystagmus blockage syndrome(NBS) Congenital nystagmus dampens with convergence or adduction. Demonstrates an esotropia to dampen nystagmus. Features  Infantile esotropia  Pseudoabducens palsy  Manifest nystagmus occurs when eye moves from adduction to abduction. All patients with infantile esotropia should be screened for nystagmus. Gauri S Shrestha, M.optom, FIACLE
  26. 26. Periodic alternating nystagmus Unusual form of congenital motor jerk nystagmus Patient starts with a jerk nystagmus in one direction & lasts for 60 – 90 sec & then slowly begins to dampen. A period of no nystagmus lasts for 10-20 seconds and then the nystagmus begins to jerk in opposite direction (60-90 sec). Cycle again repeated. Etiology not known but is associated with oculocutaneous albinism. Gauri S Shrestha, M.optom, FIACLE
  27. 27. Characteristics of CongenitalNystagmus Binocular Similar amplitude in both eyes Usually uniplanar (horizontal) in all gazes Distinctive waveforms Diminished (damped) by convergence Increased by fixation attempt Superimposition of latent component Intensity increase at lateral gazes – fast phase towards the direction of gaze Associated head oscillation No oscillopsia Abolished in sleep Gauri S Shrestha, M.optom, FIACLE
  28. 28. Acquired : Spasmus nutans combination of nystagmus, involuntary head nodding and abnormal head posture. Intermittent rapid small oscillation with onset at 3-18 months, resolution at 36 months. A rare constellation of ocular oscillation  Head nodding &  Torticollis  Begins in infancy (usually between 4 and 18 months of age)  Disappears in childhood (usually before 3 years of age). Gauri S Shrestha, M.optom, FIACLE
  29. 29. Acquired Acquired pendular nystagmus - result of cerebellar or brainstem lesions. equal amplitude of nystagmus in all gazes Acquired jerk nystagmus - (slow and fast phase), may be horizontal, vertical or rotary, due to supranuclear defect Vestibular nystagmus - horizontal jerky nystagmus with rotary or vertical element, due to the destruction of inner ear, vestibular nerves and vestibular nuclei. Gauri S Shrestha, M.optom, FIACLE
  30. 30. Acquired Gaze evoked nystagmus -an inability to maintain the eyes in a lateral or vertical gaze position. The eyes drift back to the primary position, then make a correction saccade to look in the position of defective gaze. Cause is supranuclear defect Dissociated nystagmus -oscillatory movements of eyes, dissimilar in direction, amplitude and speed. Cause is internuclear ophthalmoplegia Convergence retraction nystagmus -on attempted upgaze, eyes are converging and retracting with nystagmoid jerk movements Gauri S Shrestha, M.optom, FIACLE
  31. 31. See-saw nystagmus Unusual & dramatic type. Has both vertical & Torsional components. Eyes make alternating movement of elevation & intorsion followed by depression & extorsion. Often associated with lesions in the rostral midbrain or the suprasellar area. Visual field defects are bitemporal hemianopia. Neuroradiologic evaluation mandatory. Gauri S Shrestha, M.optom, FIACLE
  32. 32.  Downbeat nystagmus: jerky vertical nystagmus seen with increased amplitude on downgaze. The eyes drift up and beat down again. Cause is CNS lesion Upbeat nystagmus :jerky vertical nystagmus seen with increased amplitude on upgaze. The eyes drift down and beat up again. Cause is lesion of cerebellum or medulla. Periodic alternating nystagmus :jerk nystagmus is seen which alters in direction with every few minutes. Cause may be drugs or multiple sclerosis Gauri S Shrestha, M.optom, FIACLE
  33. 33. Downbeat nystagmus Gauri S Shrestha, M.optom, FIACLE
  34. 34. Upbeat nystagmus Gauri S Shrestha, M.optom, FIACLE
  35. 35. Nystagmus Management Neurological Work-up and appropriate medical treatment  Refer if necessary Provide Best Corrected VA  Recommend with contact lenses Utilize Null Point  Certain eye/head position that minimizes nystagmus Vision Therapy Gauri S Shrestha, M.optom, FIACLE
  36. 36. How Can You Utilize Null Point? Locate with version (ocular motility) testing Use of Prisms:  Base-Out: if convergence reduces nystagmus  Yoked: in extreme head turn reduces nystagmus  Base toward Null point to reduce head turn  Use Equal power (RE, LE) EOM Surgery:  Move Null point to primary position Gauri S Shrestha, M.optom, FIACLE
  37. 37. Gauri S Shrestha, M.optom, FIACLE
  38. 38. Gauri S Shrestha, M.optom, FIACLE
  39. 39. Gauri S Shrestha, M.optom, FIACLE
  40. 40. Near Work With Nystagmus The angle of vision is important.  Null point. Adopt a head posture Small print.  Visual Aids, Large print materials. Good Lighting  Be Careful with Light sensitive paients Reading speed  Reduced due to the extra time needed to scan  Should not be taken as a sign of poor reading. Gauri S Shrestha, M.optom, FIACLE

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