See-saw Nystagmus

Update Item Information
Identifier 163-2
Title See-saw Nystagmus
Creator Shirley H. Wray, MD, PhD, FRCP
Contributors Ray Balhorn, Video Compressionist
Affiliation (SHW) Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital, Boston, Massachusetts
Subject Pendular See-saw Nystagmus; Bitemporal Hemianopia; Craniopharyngioma
History The patient is a 21 year old woman who was referred to an endocrinologist for evaluation of amenorrhea. She was found to have bitemporal hemianopia and compression of the chiasm. CT Brain showed: A partially cystic, partially solid suprasellar mass with focal calcification consistent with a craniopharyngioma (Rathke pouch tumor). She was referred to the Massachusetts General Hospital for a neurosurgical opinion. Neuro-ophthalmological examination: Visual acuity OD: 20/30, OS: 20/20 Dense bitemporal hemianopia Normal pupils Fundus examination Mild temporal pallor of the right optic disc Left optic disc normal Ocular Motility: Pendular seesaw nystagmus One-half cycle consisted of: Depression and extorsion (excyclotorsion) of the left eye synchronous with elevation and intorsion (incyclotorsion) of the right eye During the next half cycle, the movements reversed in each eye. Seesaw Nystagmus: Seesaw nystagmus is a form of pendular nystagmus in which one half cycle consists of elevation and intorsion of one eye and synchronous depression and extortion of the other eye, with the vertical and torsional movements reversing during the next half cycle.
Pathology Visual loss
Disease/Diagnosis Pendular Seesaw Nystagmus, Craniopharyngioma
Clinical This case is the only example of seesaw nystagmus that I have in my collection. Viewing both eyes together one can see: • A rocking movement of the eyes • The wave form is pendular • The cycles are rapid One-half cycle • Right eye elevates and intorts synchronous with • The left eye depressing and extorts Next-half cycle • The vertical and torsional movements of each eye are reversed Pathogenesis: Measurement of horizontal, vertical and torsional components of these oscillations using the magnetic search coil technique has clarified the characteristics and pathogenesis of seesaw nystagmus occurring with lesions at several sites in the nervous system. Two wave forms are recognized. 1. Pendular (seesaw) 2. Jerk (hemi-seesaw) in which the slow phase corresponds to one-half cycle. Pendular seesaw nystagmus has most frequently been described with large parasellar tumors, as in this case, and so these oscillations have been attributed to either secondary midbrain compression or to the effects of commonly associated visual field defects. Pendular seesaw nystagmus has been reported with visual loss, and has been documented to develop in a patient who progressively lost vision due to retinitis pigmentosa. It may also develop and become symptomatic years after head injury causing bitemporal field defects and increase following a blink. Congenital seesaw nystagmus is present in a mutant strain of dogs that lack an optic chiasm and in patients in whom imaging and visual evoked studies have suggested a similar developmental defect. Thus, one conclusion is that visual inputs - especially crossed inputs - are important for optimizing vertical-torsional eye movements. Under natural conditions, seesaw eye movements appear to compensate for ear-to-shoulder head roll, especially when the subject views a target located off the midsagittal plane. Cross visual inputs are presumably necessary to keep this response calibrated and if removed might lead to seesaw oscillations. Jerk seesaw nystagmus (hemi-seesaw nystagmus) is reported in patients with lesions in the region of the interstitial nucleus of Cajal (INC). Such patients often have a contralateral ocular tilt reaction; with a left INC lesion, this would cause right head tilt, skew deviation (left hypertropia), tonic intorsion of the left eye and extorsion of the right eye, and the misperception that earth-vertical is tilted to the right. The ocular tilt reaction represents an imbalance of central otolithic projections from vestibular nuclei to the INC. Hemi-seesaw nystagmus has also been reported in patients with lower brainstem lesions, including the medial medulla, with hindbrain anomalies, such as Chiari malformation and as a component of the syndrome of oculopalatal tremor. Review Table 10-5 Etiology of seesaw and hemi-seesaw nystagmus. ref (8)
Presenting Symptom Visual loss
Ocular Movements Pendular See-saw Nystagmus
Neuroimaging The brain CT is not available in this patient.
Treatment Neurosurgical decompression of the chiasm
Date 1979
References 1. Averbuch-Heller L, Leigh RJ. Saccade-induced nystagmus. Neurology 1996;46:289. 2. Barton JJS. Blink-and saccade-induced seesaw nystagmus. Neurology 1995;45:831-833. 3. Bergin DJ, Halpern J. Congenital see-saw nystagmus associated with retinitis pigmentosa. Ann Ophthalmol 1986;18:346-349. 4. Brandt T. Dieterich M. Vestibular syndromes in the roll plane: topographic diagnosis from brain stem to cortex. Ann Neurol 1994;36:337-347. 5. Choi KD, Jung DS, Park KP, Jo JW, Kim JS. Bowtie and upbeat nystagmus evolving into hemi-seesaw nystagmus in medial medullary infarction: possible anatomic mechanisms. Neurology 2004;62:663-665. 6. Daroff RB. Seesaw Nystagmus. Neurology 1965;15:874-877. 7. Drachman DA. Seesaw nystagmus. J neurol Neurosurg Psychiatry 1966;29:356-361. 8. Eggenberger ER. Delayed-onset seesaw nystagmus posttraumatic brain injury with bitemporal hemianopia. Ann N Y Acad Sci. 2002 Apr;956:588-91. 9. Halmagyi GM, Aw ST, Dehaene I, Curthoys IS, Todd MJ. Jerk-waveform see-saw nystagmus due to unilateral meso-diencephalic lesion. Brain. 1994;117:775-788. 10. Leigh JR, Zee DS. Diagnosis of Nystagmus and saccadic Intrusions. Ch 10, 475-558. In: The Neurology of Eye Movements. 4th Edition. Oxford University Press, New York 2006. 11. May EF, Truxal AR. Loss of vision alone may result in see-saw nystagmus. J Neuroophthalmol 1997;17:84-85. 12. Seidman SH, Telford L, Paige GD. Vertical, horizontal, and torsional eye movement responses to head roll in the squirrel monkey. Exp Brain Res 1995;104:218-226. 13. Zimmerman CF, Roach ES, Troost BT. See-saw nystagmus associated with Chiari malformation. Arch Neurol 1986;43:299-300.
Language eng
Format video/mp4
Type Image/MovingImage
Source 16 mm Film
Relation is Part of 906-4, 923-2
Collection Neuro-Ophthalmology Virtual Education Library - Shirley H. Wray Neuro-Ophthalmology Collection:
Publisher North American Neuro-Ophthalmology Society
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit:
ARK ark:/87278/s64777g0
Setname ehsl_novel_shw
ID 188591
Reference URL