Subtle Torsional Pendular Nystagmus in Oculopalatal Tremor (OPT)

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a 50-year-old woman who presented with imbalance, and MRI demonstrated a right cerebellar cavernous malformation. She underwent surgery to resect the malformation, and post-operatively experienced right hemiparesis and ataxia. Six months after the surgery, balance worsened and vision became "blurry" despite normal afferent function. Exam demonstrated mild torsional pendular nystagmus OU and subtle rhythmic twitching of the right mentalis (not seen in the video). Palatal tremor was also seen, synchronous with the facial muscle twitching. When the patient was asked to gently close her eyes, vertical ocular oscillations (again synchronous with the palatal tremor) were apparent. Even when nystagmus due to oculopalatal tremor (OPT) is subtle or absent, eyelid closure will usually bring out (e.g., palatal tremor without nystagmus is usually seen with progressive ataxia and palatal tremor [PAPT], although rhythmic oscillations can still be brought out with gentle eyelid closure) or accentuate vertical ocular oscillations, a finding that is sometimes referred to as ocular synchrony. MRI T2/FLAIR sequences demonstrated a hyperintense left inferior olivary nucleus (figure), consistent with the theory of olivary hypertrophy, which is thought to generate OPT. When pendular nystagmus of unclear origin is appreciated, regardless of whether it is subtle, monocular, disjunctive, dissociated or conjugate, the examiner must have a suspicion for OPT and view the palate at rest. [[Number of Figures and legend for each: 1, MRI FLAIR sequence demonstrating a hyperintensity of the left inferior olivary nucleus.Number of Videos and legend for each: 1, This is a patient with oculopalatal tremor, with subtle nystagmus that increased with eyelid closure. ]] Find associated figures, CLICK HERE: https://collections.lib.utah.edu/details?id=1279193 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: This patient presented with imbalance, and MRI demonstrated a right cerebellar cavernous malformation. She underwent surgery to resect the malformation, and post-operatively experienced right hemiparesis and ataxia. Six months after the surgery, balance worsened and vision became "blurry" despite normal afferent function. Exam demonstrated mild torsional pendular nystagmus OU and subtle rhythmic twitching of the right mentalis (not seen in the video). Palatal tremor was also seen, synchronous with the facial muscle twitching. When the patient was asked to gently close her eyes, vertical ocular oscillations (again synchronous with the palatal tremor) were apparent. Even when nystagmus due to oculopalatal tremor (OPT) is subtle or absent, eyelid closure will usually bring out (e.g., palatal tremor without nystagmus is usually seen with progressive ataxia and palatal tremor [PAPT], although rhythmic oscillations can still be brought out with gentle eyelid closure) or accentuate vertical ocular oscillations, a finding that is sometimes referred to as ocular synchrony. MRI T2/FLAIR sequences demonstrated a hyperintense left inferior olivary nucleus (figure), consistent with the theory of olivary hypertrophy, which is thought to generate OPT. When pendular nystagmus of unclear origin is appreciated, regardless of whether it is subtle, monocular, disjunctive, dissociated or conjugate, the examiner must have a suspicion for OPT and view the palate at rest. https://collections.lib.utah.edu/ark:/87278/s6rc1227