|Title||Are Anemia and Hypotension Causally Related to Perioperative Ischemic Optic Neuropathy?|
|Creator||Shin C. Beh, MD, Teresa C. Frohman, PA-C, Elliot M. Frohman, MD, PhD|
|Affiliation||Baylor College of Medicine (RF), Houston, Texas; and Department of Ophthalmology (KCG), University of Cincinnati, Cincinnati Eye Institute, Cincinnati, Ohio|
|Abstract||In this issue of Journal of Neuro-Ophthalmology, M. Tariq Bhatti, MD and Mark L. Moster, MD, will discuss the following 6 articles.|
State-of-the-Art Review rie Biousse, MD Section Editors: Vale Steven Galetta, MD Cerebellar Control of Eye Movements Shin C. Beh, MD, Teresa C. Frohman, PA-C, Elliot M. Frohman, MD, PhD Background: The cerebellum plays a central role in the online, real-time control, and long-term modulation of eye movements. Evidence acquisition: We reviewed the latest (ﬁfth) edition of Leigh and Zee's textbook, The Neurology of Eye Movements, and literature in PUBMED using the following terms: cerebellum, ﬂocculus, paraﬂocculus, vermis, oculomotor vermis, dorsal vermis, caudal fastigial nucleus, fastigial oculomotor region, uvula, nodulus, ansiform lobule, eye movements, saccades, ipsipulsion, contrapulsion, smooth pursuit, vergence, convergence, divergence, gaze-holding, down beat nystagmus, vestibulo-ocular reﬂex (VOR), angular VOR, translational VOR, skew deviation, velocity storage. Results: The cerebellum is vital in optimizing the performance of all classes of gaze-shifting and gaze-stabilizing reﬂexes. The ﬂocculus-paraﬂocculus are crucial to VOR gain and direction, pulse-step matching for saccades, pursuit gain, and gaze-holding. The ocular motor vermis and caudal fastigial nuclei are essential in saccadic adaptation and accuracy, and pursuit gain. The nodulus and ventral uvula are involved in processing otolothic signals and VOR responses, including velocity storage. Conclusions: The cerebellum guarantees the precision of ocular movements to optimize visual performance and occupies a central role in all classes of eye movements both in real-time control and in long-term calibration and learning (i.e., adaptation). Journal of Neuro-Ophthalmology 2017;37:87-98 doi: 10.1097/WNO.0000000000000456 © 2016 by North American Neuro-Ophthalmology Society T he goal of the efferent visual system is to direct and maintain the angle of gaze on an object of regard, thereby guaranteeing the best possible visual acuity and clarity. Several mechanisms are crucial in attaining this goal: Departments of Neurology (SCB, TCF, EMF), and Ophthalmology (EMF), University of Texas Southwestern Medical Center, Dallas, Texas. T. C. Frohman has received speaker and consultant fees from Genzyme, Novartis and Acorda. E. M. Frohman has received speaking and consulting fees from, TEVA Neuroscience, Genzyme, Acorda, and Novartis. The remaining author reports no conﬂicts of interest. Address correspondence to Shin C. Beh, MD, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235; E-mail: firstname.lastname@example.org Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 (A) saccades, which direct the eyes to the object of regard; (B) ﬁxation and pursuit tracking, which detects (and corrects for) retinal image drift, and suppresses unwanted saccades; (C) the vestibulo-ocular reﬂex (VOR) that compensates for head perturbations at short latency to preserve visual acuity during locomotion; and (D) the gaze-holding system, which counteracts the elastic forces of orbital tissue (1-3). In species with frontally directed eyes with central foveas, the vergence system enables bifoveal ﬁxation of a single object of regard by correctly aligning the visual axes (1). The cerebellum plays a vital role in ensuring the precision and accuracy of ocular movements regardless of changes in head or body positions and is intimately involved in controlling gaze-shifting and gaze-stabilizing reﬂexes, both in their real-time, immediate modulation, and in their long-term calibration (1). Three cerebellar regions are especially important for ocular motor control (Fig. 1): 1. ocular motor vermis (OMV) and caudal fastigial nuclei (CFN); 2. ventral uvula and nodulus; and 3. ﬂocculus and paraﬂocculus To maintain visuomotor precision, the cerebellum continuously monitors and adapts the network's performance. The cell groups of the paramedian tract (PMT) receive collaterals from all ocular motor neurons and in turn convey efference copy signals to the ﬂocculus, paraﬂocculus, and vermis (1). In addition, retinal slip signals are conveyed from the inferior olivary nucleus (ION) to the contralateral ﬂocculus via climbing ﬁbers (1,4). The main afferents to the ﬂocculus and paraﬂocculus are mossy ﬁbers from the medial vestibular nucleus (MVN), superior vestibular nucleus (SVN), nucleus prepositus hypoglossi (NPH), nucleus reticularis tegmenti pontis (NRTP), and cell groups of the PMT, as well as climbing ﬁbers from the ION (1,4). The main efferents from the ﬂocculus and paraflocculus travel to the ipsilateral SVN, MVN, and Y-group (1). Major inputs to the nodulus and ventral uvula are mossy ﬁbers arising from the ipsilateral vestibular nerve (with preferential input from the semicircular canals to the nodulus, and the sacculus to the ventral uvula), SVN, MVN, and NPH, 87 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review FIG. 1. Structures of the cerebellum subserving visuomotor function. The principal structures that play an important role in cerebellar visuomotor function are the ocular motor vermis (lobules VI and VII), caudal fastigial nuclei (or fastigial oculomotor region), ventral uvula, nodulus, ﬂocculus, and paraﬂocculus. The ventral uvula and nodulus together form the caudal vermis. The ﬂocculus-paraﬂocculus and caudal vermis together constitute the vestibulocerebellum. as well as ION climbing ﬁbers (1,4). Important efferents project to the SVN, MVN, and the Y-group (1). The OMV receives mossy ﬁber afferents from the pontine paramedian reticular formation (PPRF), NRTP, vestibular nuclei, NPH, and dorsolateral and dorsomedial pontine nuclei, as well as ION climbing ﬁbers (1,4,5). Efferent projections from the OMV Purkinje cells are directed to the ipsilateral CFN (1). The CFN also receive climbing ﬁber afferents from the ION and mossy ﬁbers from pontine nuclei (particularly the NRTP) (1,6). CFN efferents project primarily to the contralateral CFN, before travelling via the uncinate fasciculus in the superior cerebellar peduncle to the omnipause neurons in the pontine raphe, contralateral brainstem burst neurons (rostral medulla, PPRF, and rostral interstitial nucleus of the 88 medial longitudinal fasciculus [riMLF]), NRTP, central mesencephalic reticular formation, periaqueductal gray, nucleus of the posterior commissure, vestibular nuclei, thalamus, and bilateral rostral poles of the superior colliculi (1,4-6). VERGENCE Clinical observations indicate an important role for the cerebellum in vergence eye movements. A range of disorders in cerebellar disease has been reported including convergence insufﬁciency and esodeviation during distance viewing (1). The OMV, CFN, and posterior interposed nuclei (PIN) are involved in vergence (7-10). Neurons controlling Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review vergence project to the NRTP from the medial superior temporal area (MST), supplementary eye ﬁeld (SEF), frontal eye ﬁeld (FEF), superior colliculi, and mesencephalic pretectum. The NRTP subsequently projects to the OMV and deep cerebellar nuclei (5,11-13). Esodeviation at distance has been recognized in cerebellar disease (1,7). To understand how cerebellar lesions affect vergence, it is important to note that neural pathways for convergence and divergence are separately organized; divergence-related neurons in the PIN receive input from the ventral paraﬂocculus and OMV, while the convergence is controlled by the OMV-CFN pathway (1,9,10,12-16). Further, since divergence-related neurons in the OMV may be more susceptible to injury, and convergence may be better compensated for (7), vermal lesions are more often associated with incomitant esodeviation (5,17). SKEW DEVIATION Skew deviation is a vertical misalignment of the eyes resulting from lesions disrupting otolithic input to the interstitial nucleus of Cajal (1). When skew deviation is associated with ocular torsion (with the upper poles of the eyes rotated toward the lower ear) and a head tilt (toward the lower eye), this combination is called the ocular tilt reaction (OTR) and is often associated with deviation of the subjective visual vertical (1). The OTR is believed to arise from an imbalance in the otolith-colic reﬂexes, part of the phylogenetically ancient righting response to a lateral head tilt (1). Skew deviations have been long recognized as a feature of cerebellar disease (1,17). Sometimes, the vertical misalignment may change with horizontal position, with the abducting eye being higher (the alternating skew deviation) (17-23). The cerebellum (speciﬁcally, the uvula, nodulus, biventer lobe, and dentate nucleus) is involved in otolithic signal processing, ensuring the accuracy of the internal representation of the earth-vertical (24,25). Lesions affecting these structures may cause a skew deviation or OTR, presumably by disrupting the symmetry of the otolithic pathways (24,26). Generally, uvulonodular and dentate nuclear lesions result in a contraversive OTR, while lesions affecting the biventral or inferior semilunar lobule cause an ipsiversive OTR (1,24). SACCADES Saccades are rapid eye movements that redirect the fovea from one object of interest to another and must be fast and accurate to ensure visual clarity. Human saccades jump to a target within w250 milliseconds are fast (w600°/s), brief (w30-100 milliseconds), accurate, and stop abruptly (with little subsequent ocular drift) (27). Saccades are generated by a pulse-step command. To ensure accuracy, the pulse Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 command must be of the correct magnitude; to keep the eye still following the saccade, the step command must match that of the pulse and be sustained for the duration of the ﬁxation (17). Cortical eye ﬁelds (frontal, parietal, and supplementary) predominantly project to the superior colliculi, the vital nodal point that integrates and relays commands from the cortical eye ﬁelds and basal ganglia to the brainstem saccadegenerator, as well as to the OMV and CFN by way of the NRTP and the dorsolateral pontine nuclei (1,5,6,22,27- 31). The cerebellum also receives input from the cortical eye ﬁelds, NPH, and premotor burst-neurons in the brainstem reticular formation (1). The cerebellum in turn projects efferents back to these structures, including projections to the cortical eye ﬁelds (via the thalamus) and superior colliculi (1). The cerebellum is essential to saccadic sensorimotor adaptation and accuracy. Its immediate responsibility is propelling and accelerating the eyes to a target of interest, monitoring the progress of the saccade, and ensuring that the saccade lands on target by choking the pulse drive off at the precise time; its long-term role is to assure accuracy by adapting for persistent end-point errors (4,32). Total cerebellectomy abolishes saccadic adaptation for both pulse-size and pulse-step match (33). The OMV and CFN play a crucial role in saccadic adaptation and accuracy. Stimulation studies show that OMV stimulation produces ipsiversive saccades, and that it is organized topographically; lobule V produces upward and horizontal saccades, while lobules VI and VII elicit horizontal and downward saccades (1). The CFN and OMV show signiﬁcant changes in electrical activity related to saccadic adaptation; furthermore, brainstem structures (especially the NRTP) that are intimately linked by afferent and efferent projections with the CFN and OMV also demonstrate changes in neuronal activity during adaptation (34). Inactivation of the CFN abrogates saccadic adaptation (34-36); however, there is evidence that saccadic adaptation can occur during the period of CFN inactivation but cannot be expressed until this output pathway regains function, suggesting that the OMV is the critical cerebellar structure required for saccadic adaptation, rather than the CFN (34,35). Lesion studies suggest that while OMV-CFN lesions impair the pulse-size adaptation (resulting in pulse-size dysmetria), pulse-step match is controlled by the ﬂocculus-paraﬂocculus (1,37). Apart from these structures, there is evidence that the lateral cerebellar hemispheres also participate in saccade adaptation (38). Conjugate saccade pulse dysmetria is a classic sign of cerebellar disease (1,17,18,39). Bilateral OMV lesions that spare the CFN cause hypometric saccades; on the other hand, unilateral CFN lesions result in hypometric contraversive and hypermetric ipsiversive saccades (35,40-49). Total cerebellectomy and bilateral CFN inactivation causes saccadic hypermetria (33,48,50). As such, we can infer that the CFN overcomes the inherent hypermetric tendency of 89 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review the brainstem saccade pulse-generator (41), presumably by balancing the activity between omnipanuse neurons and excitatory and inhibitory burst-neurons (51-55). To guarantee the eyes land on target, the OMV monitors saccade performance and adjusts its inhibition of the CFN (4) to ensure that saccade-related CFN neurons ﬁre just before the onset of contraversive saccades and toward the end of ipsiversive saccades (36,51,56-58); this discharge pattern suggests that the CFN provides the "push" for contraversive saccades to propel the eyes toward a target and applies the "brakes" for ipsiversive saccades to stop on target. Therefore, in unilateral CFN lesions, contralesional saccades are hypometric due to insufﬁcient "push," and ipsilesional saccades are hypermetric as a result of damaged "brakes." On the other hand, unilateral OMV lesions cause hypermetric contraversive and hypometric ipsiversive saccades, and bilateral OMV damage results in bilateral hypometric saccades because their inhibitory effect on the CFN is lost (thereby "disinhibiting the inhibitors") (59). Ocular lateropulsion refers to horizontal conjugate gaze deviation during eye closure, either toward (ipsipulsion) or away from (contrapulsion) the side of the lesion, that is, corrected by a saccade when the eyes are opened. Ocular lateropulsion is typically accompanied by saccadic lateropulsion and horizontal misdirection of vertical saccades. In ipsipulsion, damage to the inhibitory climbing ﬁbers from the contralateral ION (travelling in the inferior cerebellar peduncle) to OMV Purkinje cells leads to increased inhibition of the ipsilateral CFN (mimicking the effects of an ipsilateral CFN lesion) (60,61). This results in hypometric contraversive and hypermetric ipsiversive saccades. On the other hand, contrapulsion results from damage to ﬁbers traveling in the uncinate fasciculus from the contralateral CFN to the ipsilateral PPRF (62,63), leading to hypometric ipsilesional and hypermetric contralesional saccades (Fig. 2). CFN damage also affects vertical saccades and gaze position, since both CFNs are active during vertical saccades (36,55,56). In unilateral lesions, the unopposed "push" from the unaffected CFN results in ipsilesional horizontal FIG. 2. Pathways for ocular and saccadic lateropulsion. Inhibitory climbing ﬁbers travel from the inferior olivary nucleus (ION) to the contralateral ocular motor vermis (OMV) and pass through the inferior cerebellar peduncle. The OMV then projects to and exerts inhibitory control over the ipsilateral caudal fastigial nuclei (CFN). Efferents from the CFN project to the fellow CFN and subsequently travel via the uncinate fasciculus (in the superior cerebellar peduncle) to the contralateral paramedian pontine reticular formation (PPRF), an integral part of the brainstem saccade brainstem generator. The CFN also send efferent projections to the superior colliculi, thalamus, rostral interstitial nucleus of the medial longitudinal fasciculus, and mesencephalic reticular formation. In ipsipulsion, damage to the inhibitory climbing ﬁbers from the contralateral ION to OMV Purkinje cells leads to increased inhibition of the ipsilateral CFN, resulting in hypometric contraversive and hypermetric ipsiversive saccades. Vertical saccades demonstrate an ipsilesional horizontal bias in saccadic ipsipulsion. Contraversive pursuit may also be impaired in this disorder. On the other hand, contrapulsion results from damage to ﬁbers traveling in the uncinate fasciculus from the contralateral CFN (efferents originating from the fellow CFN), to the ipsilateral PPRF, leading to hypometric ipsilesional and hypermetric contralesional saccades. Vertical saccades demonstrate a contralesional horizontal bias in this condition. 90 Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review deviation of vertical saccades. Additionally, the eyes are often slightly deviated ipsilesionally during ﬁxation (48,55). In saccadic lateropulsion, vertical saccades exhibit a curved trajectory due to cross-coupling of horizontal bias into vertical eye movements. The horizontal bias is directed contralesionally in contrapulsion and vice versa (1,63,64). Further, the amplitude of horizontal misdirection may be greater in upward compared to downward saccades (65). The posterior inposed nuclei (PIN) ﬁre for every saccade (66) and receive projections from saccade-related pontine nuclei via the paraﬂocculus (67,68). Each PIN, in turn, conveys efferent projections to the contralateral superior colliculi and interstitial nucleus of Cajal (69). In primates, PIN inactivation results in hypermetric upward saccades and hypometric downward saccades, as well as upward deviation of horizontally directed saccades (70). The cross-coupling of inappropriate vertical components into horizontal saccades has also been observed with pontine lesions (71), perhaps reﬂecting damage to the brainstemPIN circuitry. Saccadic intrusions are a feature of certain disorders that affect the cerebellum and/or brainstem. Square-wave jerks are prominent sign in certain cerebellar disorders (e.g., Friedreich ataxia, spinocerebellar ataxia 8); while the precise etiopathological basis is unclear, some have suggested that a dysfunctional inhibitory system (which includes the cerebellum) is to blame (1,72). Macrosaccadic oscillations (thought to be an extreme form of saccadic hypermetria) have been recognized in midline cerebellar lesions affecting the CFN and are hypothesized to be due to CFN output dysfunction (72). Ocular ﬂutter and opsoclonus are believed to arise in cerebellar disorders that impair Purkinje cell inhibition of the CFN, resulting in premotor burst neuron oscillations (1,72). PURSUIT The cerebellum plays a crucial role in the smooth eye tracking of a moving target, either when the head is still (i.e., smooth pursuit), or when the head is passively moving with the target (i.e., VOR cancelation). Complete cerebellectomy abolishes smooth pursuit in humans and monkeys (19,73,74). The main cerebellar structures involved in pursuit eye movements are the ﬂocculus-paraﬂocculus, OMV, CFN, and ansiform lobule (hemisphere lobule VII). The nodulus, uvula, and lateral cerebellar hemispheres also contribute to pursuit (7,75-83). In monkeys, bilateral ﬂocculus and paraﬂocculus ablation completely impairs smooth pursuit (75,80), while unilateral inactivation impairs ipsilateral pursuit (84). In humans, the paraﬂocculus plays a greater role in smooth pursuit compared to the ﬂocculus, which is predominantly concerned with the VOR (16, 80). As part of the network that controls smooth pursuit, the paraﬂocculus receives afferents from the dorsolateral pontine nuclei and mossy ﬁber Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 input from the vestibular nuclei, NPH, PMT, as well as climbing ﬁbers from the contralateral ION (16,67,85). The OMV (which receives pursuit input from the NRTP) is also important in pursuit tracking. In addition to encoding gaze velocity during pursuit tracking, the OMV Purkinje cells also respond to retinal slip velocity and hence encode target velocity in space (1,76,86). OMV lesions affect the initiation of smooth pursuit (reducing initial acceleration by over 50%) and affect pursuit adaptation to novel stimuli (87). In contradistinction, uvulonodular lesions impair sustained pursuit without affecting pursuit initiation (81). CFN neurons ﬁre most vigorously during contraversive pursuit and just before the end of ipsiversive pursuit (88,89). As such, their role in pursuit is similar to their role in saccades-to accelerate contraversive pursuit and to slow down ipsiversive pursuit so that the eyes accurately match the target's velocity (89). Unilateral CFN lesions impair contralateral pursuit, while unilateral OMV damage affects ipsilateral pursuit (87,89). Interestingly, while bilateral OMV lesions cause bilateral pursuit deﬁcits (87), bilateral CFN damage leaves pursuit relatively intact (89), suggesting that pursuit deﬁcits from CFN lesions are the result of asymmetry between the 2 CFN (4). In vertical pursuit, the CFN, nodulus, and ventral uvula are more active during downward pursuit and as such, lesions of these structures may cause decreased downward pursuit gain (87-89). The ansiform lobule receives input from the frontal cortical areas (via the pontine nuclei) and from the nucleus of the optic tract (via climbing ﬁbers from the ION); it is hypothesized that the ansiform lobule may help suppress background motion induced by smooth pursuit of a small target on the foreground (1,90,91). An unusual, but highly conspicuous manifestation of cavernous angiomas of the middle cerebellar peduncle (MCP) is cross-coupling of torsional into vertical eye movements, resulting in direction-changing torsional nystagmus during vertical pursuit (64). It is hypothesized that the smooth pursuit neural network is based on a vestibular labyrinthine coordinate system; vertical VOR and pursuit signals encoded in "anterior canal coordinates" are conveyed to the vestibulocerebellum via the MCP (92- 94). Therefore, unilateral MCP lesions would cause an imbalance in the torsional components during vertical pursuit, resulting in a contralesional-beating torsional nystagmus during upward tracking (due to the unopposed anterior canal signals) and a ipsilesional-beating torsional component during downward tracking (due to the unopposed posterior canal signals) (64). GAZE-HOLDING The neural integrator is inherently "leaky" and the eye position signal is a decaying exponential resulting in slow 91 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review centripetal drifting of the eyes until corrective saccadic quick-phases move the eye back to target. This is the basis for gaze-evoked nystagmus (GEN) (1). The ﬂocculus-paraﬂocculus is tasked with improving the performance of this inherently leaky neural integrator (75,95). Positive feedback loops between the cerebellum and brainstem, via connections from the NPH and MVN, to the vestibulocerebellum and PMT, optimize the performance of the neural integrator to maintain eccentric gaze stability (1,96). Floccular-paraﬂoccular lesions result in GEN (since the output of the neural integrator cannot be maintained) and postsaccadic drifts (because the step is not correctly matched to the pulse command) (1). Furthermore, since the ﬂocculus is crucial for adaptive control of the time constant of the neural integrator, the GEN from cerebellar disease is often persistent (1,97). Postsaccadic drifts are another manifestation of the pulse-step mismatch arising from ﬂocculusparaﬂocculus lesions (1,75). DOWNBEAT NYSTAGMUS Downbeat nystagmus (DBN) is a prominent and common manifestation of ﬂoccular-paraﬂoccular lesions (75,98-102). Less frequently, DBN is caused by lesions affecting the uvula/nodulus (103), OMV (104), or PMT (105). Hypothetically, the upward drift consists of 2 components-a gaze-evoked drift and an upward bias (106). The gaze-evoked drift results from a leaky gaze-holding neural integrator (106,107). The upward bias is hypothesized to consist of gravity-dependent and gravity-independent components (98,99,106). The gravity-dependent component may be the consequence of otolith-ocular reﬂex hyperactivity (98) and explain the effect of position on DBN. The pathophysiologic basis of the gravity-independent component is less clear; the most-favored hypothesis (108) is that the geometric conﬁguration of the canals predisposes to an upward ocular drift (due to relative predominance of the anterior canal pathways), that is, normally suppressed by the ﬂocculus-paraﬂocculus. Cerebellar disease unmasks this upward vestibular bias, resulting in DBN (108-113). Others have proposed that neural integrator dysfunction results in an upward shift of Listing's plane for static eye positions (104,106). Alternately, based on the observation that downward pursuit is more impaired than upward pursuit in cerebellar disease, it is possible that ﬂoccular damage causes an asymmetry of vertical smooth-pursuit signals, where a preponderance of upward velocity results in spontaneous upward drifts (1,99,102,114,115). VESTIBULO-OCULAR REFLEX By detecting head motion and position and generating compensatory eye movements, the VOR ensures that the 92 angle of gaze remains on target during head motion (1,116). The 3-neuron VOR reﬂex path consists of vestibular ganglion cells, inhibitory and excitatory oculomotor relay neurons in the medial and superior vestibular nuclei and Y-group, and the motor neurons of the ocular motor nuclei (85). The angular VOR (AVOR) stabilizes the eyes in space during angular head acceleration (1,117). On the other hand, the translational VOR (TVOR), which relies on the otolithic organs to transform linear head acceleration into angular eye rotation, stabilizes eye position to compensate for translational head movements (118-121). VOR performance needs to be continuously adjusted and optimized to correct for any change in visual circumstance (e.g., changes in spectacle lenses, disease states that affect balance) (1). VOR adaptation (changes in gain, direction, and phase) is driven by error signals from retinal slip. While vestibulocerebellar lesions do not abolish the VOR, such lesions impair VOR adaptation (80,97,116,117,122-128). The ﬂocculus is essential to VOR adaptation. It receives bilateral mossy ﬁber input primarily from the vestibular nuclei, PMT, NPH, and NRTP, as well as climbing ﬁbers from the contralateral ION (1). The ﬂocculus, in turn, projects to the ipsilateral SVN, MVN, Y-group, and basal interstitial nucleus of the cerebellum (1,129,130). Floccular Purkinje cells transform vestibular and nonvestibular (efference copies, head velocity, and retinal image slip) input into compensatory ocular motor signals that ultimately produce accurate and precise VOR responses (1,96,121,122,125,131-136). Additionally, the ﬂocculus modiﬁes VOR gain, inhibiting the horizontal VOR during low-frequency stimulation, but facilitating it at high-frequency stimulation (137). Following ﬂoccular damage, VOR gain exceeds 1 with low frequency stimulation (75,116,117,123,138), but is diminished at high frequencies (75,123,137,139). Furthermore, ﬂoccular lesions may cause VOR misdirection, as evidenced by cross-coupling of upward bias into horizontal VOR, most likely due to disinhibition of anterior canal pathways (116,117,140). The nodulus and ventral uvula receive afferent signals from the canals and otolith organs, secondary projections from the vestibular nuclei, and tertiary input from the ION (141-163). Uvulonodular efferent ﬁbers project in a topographic fashion back to the Y-group and the magnocellular layer of the MVN (1,164). The nodulus and ventral uvula are responsible for generating the TVOR (by integrating linear head acceleration signals from otolithic organs to head velocity) and controlling the velocitystorage mechanism (which enhances the low frequency performance of the AVOR) (1,162). Nodular lesions in monkeys impair the sustained component of TVOR, impair downward pursuit, and cause DBN when ﬁxation is eliminated (80,162). Clinically, uvulonodular lesions cause DBN in the dark, positional horizontal nystagmus, abnormal ocular counter-roll, and variants of the skew deviation (1). In some cerebellar diseases, the TVOR can be severely impaired despite relative preservation of AVOR Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review (93,165), suggesting that preferential uvulonodular damage occurs in certain pathologies. The velocity-storage mechanism maintains the spatial orientation of the AVOR by realigning the eye velocityvector toward the gravito-inertial acceleration vector. Since movement in a terrestrial environment activates the canals and otolith organs, these signals are processed in a head-based canal-coordinate frame (rotated relative to the cardinal axes of the head). On the other hand, velocity storage processes information in a spatially linked coordinate frame, the yaw axis of which is a combination of the head-vertical and gravito-inertial acceleration vector. In other words, the velocity-storage mechanism transforms sensory signals from a head-ﬁxed reference frame into a spatially linked reference frame (1,166-174). The nodulus and ventral uvula (with their GABAergic Purkinje projections to the ipsilateral vestibular nuclei) are critical components of the velocity-storage mechanism (171,175-179). Stimulation of the nodulus reduces the VOR time-constant, while stimulation of the uvula produces nystagmus without altering the VOR time-constant (180). Lesions of these structures prolong the velocity-storage effect for horizontal AVOR and negate the effect of maneuvers that typically shorten the duration of postrotational nystagmus (e.g., pitching the head forwards-"tilt-suppression TABLE 1. Summary of the function of the 3 principal cerebellar regions involved in ocular motor control and clinical ﬁndings arising from lesions affecting these structures Structure Flocculus and paraﬂocculus Nodulus and ventral uvula Ocular motor vermis (OMV) and caudal fastigial nucleus (CFN) Functions and Effect of Lesions of These Structures Controls: Saccade adaptation Pursuit adaptation Gaze-holding Vestibulo-ocular reﬂex (VOR) adaptation, gain, up/down asymmetry and direction Effect of Lesions: Saccadic pursuit Gaze-evoked nystagmus, and rebound nystagmus Downbeat nystagmus Impaired VOR adaptation Postsaccadic drifts Controls: Pursuit gain Integrating linear head acceleration signals from otoliths to head velocity Velocity storage Effect of Lesions: Downbeat nystagmus in the dark Impaired velocity storage (leading to prolonged postrotatory nystagmus, impaired tilt-suppression of postrotatory nystagmus, perverted headshaking nystagmus, and/or periodic alternating nystagmus) Positional nystagmus Controls: Saccade adaptation and accuracy Smooth pursuit initiation and adaptation Vergence Bilateral OMV lesions: Bilateral hypometric saccades, saccadic pursuit Bilateral CFN lesions: Bilateral hypermetric saccades, saccadic pursuit Unilateral OMV lesions: Ocular contrapulsion Saccadic contrapulsion Ipsiversive saccadic pursuit Unilateral CFN lesions: Ocular ipsipulsion Saccadic ipsipulsion (hypometric contralateral, and hypermetric ipsilateral saccades) Contraversive saccadic pursuit Adapted from Refs. 1 and 59. Beh et al: J Neuro-Ophthalmol 2017; 37: 87-98 93 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. State-of-the-Art Review nystagmus") (1,138,175,181-184). Velocity-storage dysfunction from uvulonodular damage may also account for the cross-coupling of upward bias into horizontal eye movements with low-frequency head rotation around an earthvertical axis, with sustained optokinetic stimulation with the head upright, and following horizontal head-shaking (4,116,174). PERIODIC ALTERNATING NYSTAGMUS Acquired periodic alternating nystagmus (PAN) is a spontaneous horizontal nystagmus that reverses direction at predictable intervals (approximately 90-120 seconds); during the brief transition period, vertical nystagmus or square-wave jerks may occur (1). Some patients learn to use Alexander law to partially or completely null the nystagmus by using periodic head turns in the direction of the quick phases (185,186). Smooth pursuit and optokinetic responses are usually impaired in PAN; convergence is typically spared and may sometimes suppress PAN (187,188). Uvulonodular lesions have been shown to result in PAN in both experimental studies and in humans (173,175). Since the nodulus and uvula normally inhibits velocity storage, uvulonodular damage results in excessive prolongation of rotationally induced nystagmus; normal vestibular adaptive mechanisms are activated to correct this abnormality but instead produce the alternating oscillations that characterize PAN (1,187,189). Visual ﬁxation usually suppresses these oscillations; however, diseases that cause PAN often affect the ﬂocculus and paraﬂocculus and impair this process (1). The ability of baclofen to successfully abolish PAN provides pharmacological evidence that the nodulus and uvula maintain inhibitory control over the velocity-storage mechanism using gamma-aminobutyric acid (GABA) (1,190). CONCLUSION The cerebellum ensures the precision of ocular movements and occupies a central role in all classes of eye movements, both in real-time control and in long-term calibration and learning (i.e., adaptation). The ﬂocculus-paraﬂocculus are crucial to VOR gain and direction, pulse-step matching for saccades, pursuit gain, and gaze-holding. The OMV-CFN are essential in saccadic accuracy and pursuit gain. The nodulus and ventral uvula are involved in the low-frequency VOR responses (Table 1). The most important, intriguing, and impressive role of the cerebellum in eye movement control is its ability to constantly monitor the brain's performance, detect errors, readjust, and recalibrate its responses to guarantee optimal visual acuity. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: S. C. Beh, T. C. Frohman, E. M. Frohman; b. Acquisition of data: S. C. Beh; c. Analysis and 94 interpretation of data: S. C. Beh. Category 2: a. Drafting the manuscript: S. C. Beh; b. 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