Roksolyana Tourkevich, MD, Department of Neurology The Johns Hopkins School of Medicine , Daniel R. Gold, DO, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, The Johns Hopkins School of Medicine
This is a 64-year old man who experienced imbalance and falls (usually backwards) for the last 6 months. He experienced difficulty navigating stairs and had become a messy eater (thought to be in large part due to his vertical gaze palsy), and had developed hypophonia. Exam demonstrated square wave jerks, supranuclear downward>upward palsy (i.e., improved with the vertical vestibulo-ocular reflex [VOR]), slow and hypometric horizontal saccades with very slow down>up saccades (especially apparent with optokinetic tape), convergence insufficiency, and saccadic smooth pursuit and VOR suppression. ; While a supranuclear vertical gaze palsy is the most sought after ocular motor finding when progressive supranuclear palsy (PSP) is being considered, other ocular motor abnormalities are commonly seen as well and include all of those listed above and seen in the video. Since upgaze can become impaired to some degree with normal aging (whether this is related to changes involving the orbital tissues or whether this is in part supranuclear is not clear), poor downgaze in a patient with a gait/balance disorder is more diagnostically meaningful.
Spencer S. Eccles Health Sciences Library, University of Utah