Ocular Dipping

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Identifier 004-1
Title Ocular Dipping
Ocular Movements Ocular Dipping; Bilateral Horizontal Gaze Palsy; Full Vertical Gaze
Creator Shirley H. Wray, M.D., Ph.D., FRCP, Professor of Neurology Harvard Medical School, Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Contributor Primary Shirley H. Wray, MD, PhD, FRCP, Professor of Neurology, Harvard Medical School; Director, Unit for Neurovisual Disorders, Massachusetts General Hospital
Subject Ocular Dipping; Bilateral Horizontal Gaze Palsy; Full Vertical Gaze; Locked In Syndrome; Embolic Basilar Artery Occlusion; Bilateral Pontine Infarction; Pontine Infarct; Comatose Patient
Presenting Symptom Sudden collapse
History The patient is a 32 year old woman with juvenile diabetes mellitus. She collapsed at home and was rushed to the emergency room where a diagnosis of a locked-in syndrome was made. The term Locked-in Syndrome (LiS) was coined in 1966 by Plum and Posner for a condition with the following criteria: 1. Paralysis of all cranial nerves except vertical eye movements 2. Tetraplegia 3. Preserved consciousness LiS is classically due to bilateral pontine infarction, related to basilar thrombosis, bilateral occlusion of paramedian arteries and vertebral artery dissection. Some patients have ocular bobbing. This patient had ocular dipping.
Clinical This was the first case of a unique spontaneous vertical eye movement disorder called ocular dipping that I have seen. The patient was filmed in the Intensive Care Unit soon after admission. She was locked-in but conscious. The eye movements show: • Slow conjugate downward eye movement followed by a more rapid return to midposition • Preservation of vertical gaze • Bilateral horizontal gaze palsy • Intact oculocephalic reflexes both horizontally and vertically. In this patient ocular dipping was intermittent and for several minutes her eyes remained still in midposition and then ocular dipping starts again. At one stage the patient appeared to go to sleep and her eyes moved up under semiclosed lids and adopted a V-pattern exodeviation, a common position of the eyes in coma or in sleep. The presence of ocular dipping should prompt a complete evaluation of the metabolic status of the patient because dipping is seen in metabolic encephalopathy. The patient died soon after the film was made. There are four forms of abnormal spontaneous vertical eye movements: 1. Ocular Bobbing 2. Reverse Ocular Bobbing 3. Ocular Dipping 4. Reverse Ocular Dipping Ocular bobbing is a unique vertical eye movement disorder consisting of intermittent, often conjugate, fast downward movement of the eyes followed, after a brief tonic interval, by a slower return to primary position. Attention was first directed to ocular bobbing by Fisher in 1959, and its clinical prevalence first defined by Susac, Hoyt, Daroff et al in 1970. They stressed the diversity of diseases associated with it and the differing clinical settings in which it may be encountered. They also described: 1. A monocular form of ocular bobbing which coexists with a contralateral oculomotor nerve palsy (as in this case). 2. Typical conjugate bobbing associated with paralysis of both reflex and spontaneous horizontal eye movements 3. Typical cases in which the bobbing was neither associated with coexisting paralysis of horizontal gaze nor explainable by concommittant cranial nerve palsies. Fisher recognized ocular bobbing as a sign of extensive pontine destruction particularly intrinsic pontine hemorrhage or infarction. In these patients the prognosis is poor. Fisher suggested that ocular bobbing may reflect the residual eye movements of patients who have severe limitation of horizontal and vertical eye movements.(8) Cold water calorics in these patients may show: 1. An increase in the amplitude and frequency of ocular bobbing 2. Have no demonstrable effect on ocular bobbing 3. Induce conjugate horizontal eye movements 4. Have no demonstrable effect on horizontal eye movements. The presence of normal pupillary reflexes and respiratory function in ocular bobbing suggest that major midbrain and medullary centers are intact. The Spectrum of Clinical Settings in ocular bobbing includes: Metabolic encephalopathies Obstructive hydrocephalus Vertebrobasilar insufficiency Central pontine myelinolysis Pontine glioma Cerebellar hemorrhage with brainstem compression Multiple sclerosis Bromism Trauma Ocular bobbing is also reported to occur in: Leigh's necrotizing encephalomyelopathy Alpha coma Opsoclonus/myoclonus and Convergence spasm Katz, Hoyt and Townsend reported a case of ocular bobbing that developed after the patient had a subarachnoid hemorrhage. Pathological examination of the brain documented a unilateral pontine hematoma. The term Atypical Ocular Bobbing is used when bobbing is associated with: • Spontaneous and reflex horizontal eye movements • Convergence movements - "V" bobbing • Phasic pupillary constriction • Induced by cold calorics or • In concert with a locked-in state where the vertical excursion down is greater than in the typical bobbing case. Reverse Ocular Bobbing, described by Daroff, is a rapid, conjugate jerking of the eyes upward from midposition followed by a slow return. Reverse ocular bobbing has been found to be a non-localizing sign in coma and is seen in patients deeply comatose from metabolic encephalopathy. Knobler et al described a case of inverse bobbing, in which a slow downward movement of the eyes is followed by delayed, then quick return to midposition. The term Ocular Dipping has replaced the term Inverse Bobbing. Ocular dipping is seen following anoxic coma or after prolonged status epilepticus. The generalized electroencephalographic slowing seen with these disorders suggests that cortical depression may be a necessary concomitant. In anoxic encephalopathy with ocular dipping 1. Roving conjugate or dysconjugate horizontal eye movements may be prominent 2. Normal spontaneous elicited reflex upgaze is present. 3. No pontine dysfunction is evident 4. Normal recovery is possible. The suggestion that ocular dipping maybe caused primarily by diffuse dysfunction rather than a single structural locus is supported by the absence of brainstem abnormalities in two necropsy cases and by the tendency of the eye findings to abate as patients regain consciousness. A fourth form of abnormal spontaneous vertical eye movements, termed Reverse Ocular Dipping, is also reported. Reverse ocular dipping consists of a slow upward deviation of the eyes, a brief tonic phase and then a rapid return to primary gaze. Mehler reported a unique case of a patient who was: 1. Awake and partly responsive, in contrast to all reported cases of ocular dipping and most cases with ocular bobbing which were associated with coma. 2. Had an absence of roving eye movements which were present in all reported examples of ocular dipping 3. The patient had intact oculocephalic and caloric responses, which are absent in typical ocular bobbing. The fact that reverse ocular dipping is associated with advanced metabolic or viral encephalopathy and the absence of clinical or neuroimaging signs of brainstem involvement also implicates diffuse dysfunction as a causative mechanism in this condition. However, the different clinical settings in which these two forms of ocular dipping occur suggest that they may be nosologically distinct.
Neuroimaging No neuroimaging studies are available in this patient
Disease/Diagnosis Pontine Infarct
References 1. Ash PR, Keltner JL. Neuro-ophthalmic signs in pontine lesions. Medicine 1979;58:304-319. http://www.ncbi.nlm.nih.gov/pubmed/312988 2. Boddi HG. Ocular bobbing and opsoclonus: two abnormal spontaneous eye movements occurring in the same patient: case report. J Neurol Neurosurg Psychiatry 1972;35:739-742. http://www.ncbi.nlm.nih.gov/pubmed/5084143 3. Braems M, Dehaene I. Ocular bobbing: clinical significance. Clin Neurol Neurosurg 1975;78:99-106. http://www.ncbi.nlm.nih.gov/pubmed/1222509 4. Brusa A, Firpo MP, Massa S, Piccardo A, Bronzini E. Typical and reverse bobbing: a case with localizing value. Eur Neurol 1984;23:151-155. http://www.ncbi.nlm.nih.gov/pubmed/6468456 5. Daroff RB, Waldman AL. Ocular bobbing. J Neurol Neurosurg Psychiatry 1965, 28:375-377. http://www.ncbi.nlm.nih.gov/pubmed/14338127 6. Daroff RB, Troost BT, Dell'Osso LF. Nystagmus and related ocular oscillations. In: Glaser JS ed. Neuro-Ophthalmology Hagerstown, Harper and Row 1978:219-240. 7. Drake ME Jr, Erwin CW, Massey EW. Ocular bobbing in metabolic encephalopathy: clinical pathologic, and electrophysiologic study. Neurology 1982;32:1029-1031. http://www.ncbi.nlm.nih.gov/pubmed/7202152 8. Finelli PF, McEntee WJ. Ocular bobbing with extra-axial hematoma of posterior fossa. J Neurol Neurosurg Psychiatry 1977;40:386-388. http://www.ncbi.nlm.nih.gov/pubmed/874514 9. Fisher CM. Clinical syndromes of cerebral hemorrhage. In: Fields, WS ed. Symposium of Pathogenesis and Treatment of Cerebrovascular Disease. Springfield: Charles C. Thomas, 1961;318-342. 10. Fisher CM. Ocular bobbing. Arch Neurol 1964, 11:543-546. http://www.ncbi.nlm.nih.gov/pubmed/14200662 11. Goldschmidt TJ, Wall M. Slow-Upward Ocular Bobbing. J Clin Neuroophthalmol 1987;7:241-243. http://www.ncbi.nlm.nih.gov/pubmed/2963031 12. Hameroff SB, Garcia-Mullin R, Eckholdt J. Ocular bobbing. Arch Ophthalmol 1969;82:774-780. http://www.ncbi.nlm.nih.gov/pubmed/5355265 13. Katz B. Hoyt WF, Townsend J. Ocular bobbing and unilateral pontine hemorrhage. J Clin Neuro-ophthalmol 1982, 2:193-195. http://www.ncbi.nlm.nih.gov/pubmed/6217223 14. Keane J. Pretectal pseudobobbing, five patients with "V" pattern convergence nystagmus. Arch Neurol 1985;42:592-594. http://www.ncbi.nlm.nih.gov/pubmed/4004605 15. Knobler RL. Somasundaram M, Schutta HS. Inverse ocular bobbing. Ann Neurol 1981;9:194-197. http://www.ncbi.nlm.nih.gov/pubmed/7235636 16. Larmande P, Limodin J, Henin D, Lapierre F. Ocular bobbing: abnormal eye movement or eye movement's abnormality? Ophthalmologica 1983;187:161-165. http://www.ncbi.nlm.nih.gov/pubmed/6634064 17. Leigh JR, Zee DS. Diagnosis and Central Disorders of Ocular Motility Chp 12;598-718. In: The Neurology of Eye Movements, 4th Edition, Oxford University Press, New York, 2006. 18. Mehler MF. The clinical spectrum of ocular bobbing and ocular dipping. J Neurol Neurosurg and Psychiatry 1988;51:725-727. http://www.ncbi.nlm.nih.gov/pubmed/3404172 19. Nelson JR, Johnston CH. Ocular bobbing. Arch Neurol 1970;22:348-356. http://www.ncbi.nlm.nih.gov/pubmed/5417641 20. Newman N, Gay AJ, Heilbrun MP, Dysconjugate ocular bobbing: its relation to midbrain, pontine and medullary function in a surviving patient. Neurology 1971;21:633-637. http://www.ncbi.nlm.nih.gov/pubmed/5105416 21. Paty DW, Sherr H. Ocular bobbing in bromism: a case report. Neurology 1972;22:526-527. http://www.ncbi.nlm.nih.gov/pubmed/4673449 22. Ropper AH. Ocular dipping in anoxic coma. Arch Neurol 1981;38:297-299. http://www.ncbi.nlm.nih.gov/pubmed/7224916 23. Rosenberg ML. Spontaneous vertical eye movements in coma. Ann Neurol 1986;20:635-637. http://www.ncbi.nlm.nih.gov/pubmed/3789678 24. Rudick R. Satran R, Eskin TA. Ocular bobbing in encephalitis. J Neurol Neurosurg Psychiatry 1981, 44:441-443. http://www.ncbi.nlm.nih.gov/pubmed/7264693 25. Safron AB, Berney J. Synchronism of reverse ocular bobbing and blinking. Am J Ophthalmol 1983;95:401-402. http://www.ncbi.nlm.nih.gov/pubmed/6829689 26. Stark SR, Masucci EF, Kurtzke JF. Ocular dipping. Neurology 1984;34:391-393. http://www.ncbi.nlm.nih.gov/pubmed/6538285 27. Susac JO, Hoyt WF, Daroff RB, Lawrence W. Clinical spectrum of ocular bobbing. J Neurol Neurosurg Psychiatry 1970, 33:771-775. http://www.ncbi.nlm.nih.gov/pubmed/5531897 28. van Weerden TW, van Woerkom TCAM. Ocular dipping. Clin Neurol Neurosurg 1982;84:221-226. http://www.ncbi.nlm.nih.gov/pubmed/6301733 29. Zegers de Beyl D, Flament-Durand J, Borenstein S, Brunko E. Ocular bobbing and myoclonus in central pontine myelinolysis. J Neurol Neurosurg Psychiatry 1983;46:564-565. http://www.ncbi.nlm.nih.gov/pubmed/6875591
Relation is Part of 166-11
Contributor Secondary Ray Balhorn, Video Compressionist
Reviewer David S. Zee, M.D., Johns Hopkins Hospital, 2009
Publisher Spencer S. Eccles Health Sciences Library, University of Utah
Date 1970
Type Image/MovingImage
Format video/mp4
Rights Management Copyright 2002. For further information regarding the rights to this collection, please visit: https://NOVEL.utah.edu/about/copyright
Holding Institution Spencer S. Eccles Health Sciences Library, University of Utah, 10 N 1900 E, SLC, UT 84112-5890
Collection Neuro-ophthalmology Virtual Education Library: NOVEL http://NOVEL.utah.edu
Language eng
ARK ark:/87278/s6k9653k
Setname ehsl_novel_shw
Date Created 2007-08-08
Date Modified 2018-07-30
ID 188603
Reference URL https://collections.lib.utah.edu/ark:/87278/s6k9653k
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