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Show ]. Clin. Neuro-ophthalmol. 2: 85-91, 1982, Monocular Vertical Oscillations of Amblyopia The Heimann-Bielschowsky Phenomenon J. LAWTON SMITH, M.D. JOHN T. FLYNN, M.D. HENRY J. SPIRO, M.D. Abstract The Heimann-Bielschowsky phenomenon is an unusual ocular motility pattern which may develop years following uniocular visual loss and may be mistaken as a neuro-ophthalmologic sign pointing to a posterior fossa or brain stem lesion. It consists of strictly monocular coarse, pendular vertical oscillations occurring only in the amblyopic eye. It is noted primarily with distance fixation and is inhibited by convergence or fixation. The oscillations vary between 1-5 cycles/second, and amplitude, often only 2-5 degrees, may be quite large, up to 20-30 degrees (40-60 prism diopters). A faden operation improved the disorder in one patient. The importance of recognizing this characteristic motility pattern is emphasized to ophthalmologists and neurologists. A particularly interesting ocular motility disorder which has largely escaped attention by ophthalmologists may present as a neurologic diagnostic problem in young adults. Unless the true significance of the problem is recognized, these patients may be hospitalized for extensive and quite unnecessary neuroradiologic investigations. The characteristic features of this motility are as follows: years following the onset of uniocular visual loss-congenital or more commonly acquired-the amblyopic eye will begin to make coarse, slow, pendular vertical oscillations. These ocular movements are strictly monocular occurring only in the eye with very low vision. A latent period of 1-2 years, or more often 15-20 years may elapse between loss of vision and onset of these movements. During examination, the doctor, if unfamiliar with the pattern, may call them monocular vertical nystagmus, consider the problem of a posterior fossa or brain stem disorder, and promptly alarm the patient by hospitalization and unneeded proce- From the Department of Ophthalmolo~y, Bascom Palm", Eye Institute, University of Miami, Miami, Florida. June 1982 dures and expense. This report will describe three illustrative cases, present clinical observations, review the pertinent literature, discuss the neurologic significance, comment on its relationship to dissociated vertical divergence, and present the surgical management of one case by a faden operation. Case 1 (N.F.) A 24-year-old, right-handed white man was seen April 25, 1980, through the courtesy of Dr. Sime. The patient had no eye problems until 7 years of age, when he was struck in the right eye by an arrow in Sicily. The eye was promptly surgically repaired and another operative procedure was required a year later. At about age 10 some movements of the right eye were apparent. He recalled that when playing ball or when excited the eye would move with a greater excursion. Over the years, the vision remained stable in this eye. The left eye vision remained good. Because of concern about the cosmetic appearance of his right eye, he desired another opinion. His health had otherwise been excellent. Examination revealed a vision of 4/200 in the right eye with his glasses, fixing eccentrically, but with a +12 sphere in a trial frame and a pinhole, with careful occlusion of the left eye, he S.lW 20/100 with the right eye. The left eye acuity corrected to 20/15-1 and J-l with ease. Examination revealed a classic leukoma adherens in the right eye. A dense white corneal scar was noted just below the apex of the cornea with iris pulled into it. The pupil reacted crisply to light .md no Marcus Gunn pupil was seen. Heterochromia iridis was present with a brown iris on the right and a gray-green iris on the left. Most of the lens material had been absorbed on the right. The left eye was quite normal. The ocular motility was of great interest. When the patient fixed at distance with his left eye, one could see classic Heimann-Bielschowsky phenomenon movements of the right eye. These were rather rapid, large amplitude, vertical pendular 85 Hl'im,lIln-Birlschowsky Phenomenon oscill.ltions of this eye. The left eye was still, and this W.IS .1 tot,ll1y mOO(Kular deviation. If he fixrd .1t dist.mcr ,lI1d -his chin was tipprd down so that thr eyrs wrre in up g.lzr, thr movement was notably d.lmpened. If his chin were tipprd back so th.lt he Il)l)ked in down gazr, thr ('xcursion was inrre.lsrd. It W.1S 1110rr m.ukrd whrn thr ryr W.JS in adduction .md 11'55 marked when the rye W.J5 in .1bdurtion. If the patirnt fixed with thr right ryr. or .Ittrmptrd to fix with th(' right eyr, thr moV('mrnts .Ilso damprned. P.Jrt of this .Jppeared to be due to the bct that he turned thr eye to fix eccentrically. ,md the deviation was noted to be less in up gaze. Testing the optokinetic responses binocularly showed a 4+ response with targets to the right. 4+ left. 4+ up, and 4+ down. However, when the left eye was covered and the right eye was tested ~onocularly, the response was 2+ with targets to his right, 1-2+ with targets to his left, nil to down targets, and 2+ to up targets. It appeared that one was simply bringing out the vertical phenomenon when he was given an optokinetic stimulus. A dilated fundus indirect ophthalmoscopic examination revealed a slight amount of capsular material remaining below in the right eye, and otherwise the fundi were quite normal bilaterally. The visual field was intact to large peripheral targets in the right eye, but had a dense central scotoma. The visual field was normal in the left eye. Since no afferent pupil could be detected and the fundi were normal, the central scotoma was attributed to suppression amblyopia in the right eye. Intraocular pressures were 27 right and 15 left. The impression was that he had HeimannBielschowsky phenomenon, right eye, with posttraumatic monocular surgical aphakia. and central scotoma secondary to suppression amblyopia. Heterochromia iridis, acquired, attributed to bleeding in right eye in infancy, and elevated intraocular pressure in the right eye, to be observed. The patient returned for a follow-up on February 5, 1982. He had no other complaints. The monocular vertical oscillations of the right eve were unchanged. Applanation tensions were 24 in right eye and 14 in left eye, although again the optic discs were normal and without cupping in both eyes. One drop of 0.5% Timoptic W.1S given in the right eye at 8:00 that evening, at 8:00 the next morning, and at 10: 15 a.m. the applan.Hion tensions were 13 right eye and 14 left eye. The patient was advised to use Timoptic drops in the right eve only. . Electronystagmography was performed on February 5, )982. This documrntrd the folll)wing points: I) thr pendul.u vrrtical oscill.ltions of the right eye occurred ,1t a ratr of 5 cycles/second; 2) the oscillations wrre less in up g.lze ,lnd gre.lter in down g.lze in .Jmplitude; 3) the oscill.ltions were promptly and notably dampened by convergence and were best seen with distance fixatIOn; and 4) no significant change occurred in the oscillations in the dark as compared to fixation 111 the h?ht. The patient normally noted no oSClllopsl.a and had no visual complaints, except that he d.ld not see well with the right eye. However, With an aphakic spectacle correction and a pinhole, he ~id note that the line of letters moved 111 a vertICal direction when testing his acuity, and the left eye was occluded. Summary. A 25-year-old man had a traumatic corneal perforation to the right eye at age 7. About 3 years later, monocular vertical oscillations of that eye began. When seen at age 24 and 25, he showed a characteristic monocular vertical oscillation pattern in the right eye. The movements were strictly uniocular, not seen at near being dampened by convergence, were striking with distance fixation, had a rate of 5 cycles/second, were less notable in up gaze and showed a greater excursion in down gaze, and varied in amplitude, being at times up to 20 degrees or more. No change in the pattern was seen between examinations in April 1980 and February 1982. Case 2 (O.M.B.) A 38-year-old, right-handed black woman was first seen in 1965 at 22 years of age complaining of headache and decreasing vision of 2-months duration. This patient was previously reported"> in collaboration with Dr. Thomas J. Walsh as an instance of suprasellar sarcoidosis. In essence, the patient was hospitalized in 1962 with a history of decreasing hair for 5 years. amennorhea for 1 year, and purpura. A liver biopsy was consistent with sarcoidosis. and a scalene node biopsy gave similar pathologic findings. A tuberculin skin test was negative. The patient was discharged with a diagnosis of Boeck's sarcoid and was treated with oral prednisone for the following 1! years with a good clinical response. When seen in 1965, the vision was 20/40 in her right eye and no light perception on the left. The left pupil was amaurotic, and both discs were pale. Visllal field examination revealed that only the lower nasal quadrant remained in her right eye. Pneumoencephalography revealed a 3 cm suprasellar mass. Craniotomy on July 6, 1965, revealed .1 large cystic suprasellar mass involving primarily the left optic nerve. The final impression pathologically was that this was hypothalamic-pituitary sarcoidosis involving the optic nerves and chiasm. The patient was treated with oral steroids, and has been followed regularly in the ensuing 17 years. Visual acuity remained at 20/25-20/40 in her right eye on maintenance steroids. Whenever a Journal of Clinical Neuro-ophthalmology house officer would dttempt to wean her off steroids completely, however, ,lcuity would f'lll in the right eye, dnd when the steroids would be resumed, d prompt visudl improvement would lKCUr. This hdppened on severdl ocC,lsions during the p,lst H, yedrs. A computed tomographic sc,m of the br,lin on MdY 11, 1978, W,lS reported as neg,ltive. The pdtient returned on December Ib, I<l81, compldining of d drop of vision in the right eye. Acuity WdS 20/80+1 in right eye ,lnd no light perception in the left eye. The steroids which h,ld been discontinued were resumed. Visu,ll field exdmindtion WdS unch,mged in that only the low('r ndsdl quadrant in right eye remdined to large targets. However, a new finding was now evident on her eye eXdmination. She showed d classic Heimann- Bielschowsky phenomenon in the left eye. When fixing dt distdnce, slow, coarse, pendul.u arrhythmic vertical movements of the left eye were evident. The right eye fixed steddily. The right pupil reacted 2+ to light dnd the left pupil was amaurotic. On questioning, the pdtient stdted that she hdd only noted movements of her left eye beginning within the pdSt 2-5 years, dnd thdt they hdd been slowly incredsing in dmplitude. She hdd been seen repeatedly over the years by the ophthalmology department, dnd by one of us, and these movements were not present before the examination 16 years after onset of blindness in the left eye. Electronystagmography on December 15, 1981, confinned the fact thdt the oscilldtions were pendular, slow (at a rate of 1 cycle/second). and of large amplitude (up to 30 degrees dt times). A follow-up on February 6, 1982, revealed no change in the oscillations. Summary. A 38-year-old black woman presented at age 22 with classic hypothalamic-pituitary sacroidosis proven at craniotomy. She was managed on small doses of oral steroids dnd did well during the next 16 years. Sixteen years after onset of blindness in her left eye, she was first found to have classic slow coarse pendular vertical movements of the left eye-the HeimannBielschowsky phenomenon. The movements were confinned by cinematography and electronystagmography. Case 3 (G.Y.) A 42-year-old, right-handed white married woman was first seen April 17, 1981, complaining about the appearance of her eyes. She stated that her eyes had been quite normal until age 3-4 years, when she fell from a tree and struck the left eye. At age 8, the eye began to turn in and she was told that she had a "cataract" in that eye. In 1954, at age 16, a cataract operation was performed on her June 1982 Smith, Flynn, Spiro left eye. Three months later, she had a strabismus procedure for left estropid. She did well until age 28 when the eye begdn to turn in again. In 1965, she h'ld a second strabismus operation on the left eye and again a satisfactory cosmetic alignment was obtained. The left eye IJter begJn to turn out. She then had muscle procedures for exotropia on the left eye in August 1979 and again in March IQ80. Thus, she had a cataract extraction at age 14, ,md four muscle procedures on the left eye-in IQ54, 1965, 1979, and 1980. Of interest here is that at age 28, she noted when looking in the mirror that she was developing some verticJI movements of the left eye. She was certain these were not present before age 20, and that they hJd slowly increased a bit in amplitude. Because of these movements the patient was seen in neuroophthJlmologic consultation. The history was otherwise negative. Examination on April 17, 1981, revealed right eye vision was 20/15 and left eye eccentrically was 4/200. However, the left eye with a + 13 in a trial frame could see 20/200 with difficulty. The left eye with J +20 sphere in a trial frame, and with careful complete occlusion of the right eye, could read J-1 print on a Titmus card with difficulty at 7! inches. The right pupil reacted 4+ to light and the left was 3+ to light. A fornix based flap cataract extraction with a large keyhole iridectomy WJS seen on the left. A slight residual exotropia was evident. However, the most striking findings related to the ocular motility. When fixing at near, the eyes were basically still. When fixing at distance with her right eye, a classic Heimann-Bielschowsky phenomenon was seen, with the left eye making slow, rather coarse, nearly pendular vertical oscillations. The movements were primarily going down. The eye would go up about 15-18 degrees, and then down, about 25 degrees. On left gJze, a slight limitation of Jbduction was seen, but a definite lag of adduction of the left eye was seen on right g,lze. The left eye would turn in no more thJn 50% of a normal adduction movement; J neurologist could have been surprised by this and might have described muscle paretic nystagmus in a horizontal direction of the right eye with vertical oscillations of the left eye on attempted right g,lze. The vertic,ll versions were essentially full up ,md down. Optokinetic responses, when testsed binocularly, were 3-4+ in both eyes in all directions of gaze. With the right eye only fixing, the responses were agJin essentiJlly 4+ in all directions. With the left eye only fixing, however, and the right eye covered, the responses were 2+ to right and left, up 1+ and down 0.5+. Thus, no significant difference was seen taking targets nasal to temporal and temporJI to nasal in the left eye only, but the optokinetic responses were dampened in that eye, 87 Heim,mn-Bielschowsky Phenomenon ,1I1d were better horizontally than vertically. The visual fields were normal in the right eye, and showed a central scotoma 40 degrees in diameter in th(' left eye to 10/330 white-yet with a +20 sph('re, sh(' could read J-l slowly in that eye. The ('ntral scotoma was therefore attributed to the rdr,lctive ('rror with some suppression amblyopia add('d. A dilated fundus examination was normal in both eyes. After movies, TV tapes, and electronystagmogr, lphic recordings, the patient was operated by Dr. John Flynn. A recession of the left lateral r('ctus on an adjustable suture and a Faden procedure on the left inferior rectus was performed on April 18, 1981. Postoperatively, the patient was happy with cosmetic alignment and the HeimannBielschowsky phenomenon movements were definitely dampened. Follow-up movies in November 1Q81, showed that the vertical oscillations were sti II significantly dampened from the preoperative state, and the patient was satisfied with the appearance of her eye 7 months postoperatively. Discussion When one looks into the ophthalmic literature to investigate monocular vertical eye movements occurring in an amblyopic eye, several particularly interesting papers are found pertinent to the cases under discussion. In 1902, Ernst HeimannI wrote an excellent paper on uniocular nystagmus and stated that this could be seen in three clinical settings: 1) in an old amblyopic eye, 2) with diseases of the brain and central nervous system, and 3) as a transient pattern in spasmus nutans in children. Now, at the outset, the question arises as to whether or not the pattern being described should be called nystagmus or not. If we accept the classic definition of nystagmus as an "involuntary, to-and-fro rhythmic oscillation of the eyes," we see that the word "rhythmic" is an integral part of this definition (having a pattern). Other forms of eye movements, which resemble nystagmus, but do not possess a true rhythmic pattern, may be called nystagmoid movements, or simply ocular oscillations. This is not a moot point in considering the Heimann-Bielschowsky phenomenon, for it will bear directly on the matter when one considers the pathogenesis of the disorder. Certainly variability of the deviation is an impressive attribute of Heimann-Bielschowsky phenomenon, and therefore it might be preferable to call it the uniocular vertical nystagmoid pattern of an amblyopic eye; or as designated in this report the uniocular vertical oscillations of amblyopia. H('imann stated that Alfred Graefe had observ('d a case showing nystagmus which showed dampening of the nystagmus when the amblyopic eye was f()r< (·d t() t,lb' up fix,ltion. We have been unable to obtain this original reference to date, however, and note this from a comment in Heimann's 1902 paper. Heimann described uniocular nystagmus in various neurologic diseases including brain trauma, neurosyphilis, multiple sclerosis, epilepsy, and severe hysteria. He emphasized that in these cases the monocular nystagmus was not seen as a hereditary pattern or present in the earliest years but appeared as an acquired pattern at a later age. He described classic spasmus nutans in children between 6 months and 3 years of age. Heimann was an excellent clinical observer, and noted that Neustatter had considered monocular nystagmus as a modified form of ordinary binocular nystagmus, but disagreed with that interpretation an emphasized that he was talking about a pattern in which the fixing eye was absolutely still with no degree of nystagmic movement at ali. Thus, he differentiated and emphasized the distinction between notably asymmetric eye movements and truly monocular ones. Finally, an interesting observation was also made by Heimann in that he operated on a patient with a convergent strabismus by resecting the external rectus and noted a definite diminution of the uniocular nystagmus which had been observed preoperatively in that case. A serious student of dissociated vertical eye movements was Dr. Alfred Bielschowsky. He wrote a notable paper on dissociated vertical divergence in 1931,2 and gave a series of 12 lectures on motor anomalies of the eyes published as a monograph in 1940. 1 It is obvious that Bielschowsky observed the pattern now being described and added sufficient additional information to its interpretation and clinical usefulness that it would appear prudent to name the pattern the Heimann-Bielschowsky phenomenon. We recommend to the clinician reading this paper an excellent review of Bielschowsky's contribution.4 At first look, it would appear inappropriate to introduce the concept of dissociated vertical divergence into this discussion, but it does have a definite bearing on the matter. Dissociated vertical divergence is an interesting ocular motility pattern often classified among the heterophorias and called"alternating hyperphoria" or "double hyperphoria." However, it is essential to appreciate the fact that heterophoria is a disturbance of associated eye movements, in that either eye deviates approximately the same amount but in opposite directions. This is distinctly different from dissociated vertical divergence (also termed "alternating sursumduction") in which intermittent, monocular vertical eye movements of a dissociated type occur. For example, in a left hyperphoria (or left hypertropia), when the patient is fixing with the right eye and the left eye is occluded, if one looks behind the cover, it will be seen that the left eye is turned up. If the paddle is now transferred to the opposite eye, so that the Journal of Clinical Neuro-ophthalmololN patient now fixates with the left eye, it is seen that the right eye is now turned down behind the cover. Thus, the eyes move in opposite directions in a hyperphoria. If we now consider a patient with dissociated vertical divergence, when the patient is fixing with the right eye and the left eye is occluded, if one looks behind the covering p,lddle, it will be seen that the left eye is turned up-exactly the same as in the former illustration. However, if the cover is now transferred so that the patient is now fixing with the left eye, and one looks behind the paddle occluding the right eye, the right eye is now also seen to be turned up under cover. Obviously, this is a very different situation, for at no time is the opposite shift seen on screen and cover test of a patient with pure dissociated vertical divergence that is seen in a patient with a paretic vertical muscle and an associated hyperphoria or hypertropia. If the situation were only as described thus far, we would not be able to reasonably relate dissociated vertical divergence to the problem under discussion. However, in dissociated vertical divergence, Bielschowsky noted that if one maintains continuous fixation with one eye, the occluded eye will not only tum up, but it will often move slowly up and down at irregular intervals in a pendulum like fashion, and may pass the horizontal plane. Such movements may appear spontaneously at irregular intervals, but Bielschowsky noted that this could be more easily elicited by embarrassing fixation of the eye by holding a dark glass in front of the fixing eye. He emphasized that the movements were involuntary and that voluntary effort could restore binocular fixation in such cases. Duke-Elder termed "Bielschowsky's phenomenon" as an interesting variant of this dissociation. If the deviation is apparent, and one puts a dark glass before the fixing eye, it will be seen that the nonfixing eye, originally deviated upwards, makes a vertical movement downwards, often in proportion to the degree of darkening, but frequently of about 10 degrees. Interestingly enough, if the glass is left in place, the other eye will often slowly return to its former position. During these maneuvers, the fixing eye maintains an absolutely unaltered position! Bielschowsky in 1931 found that among patients who had lost binocularity through blindness or profound amblyopia, 41.5% of cases showed an upward dissociated movement of this type in the blind or amblyopic eye while the good eye fixed. The cause of the phenomenon is unknown and various theories have been proposed, which are not the subject of this report. Another point to note is that dissociated vertical divergence is quite different from a vertical hyperphoria in that changing fixation from one eye to the other does not replace the upward movement of one by a downward displacement of the other, but also that a change in the direction of horizontal June 1982 Smith, Flynn, Spiro gaze does not alter the degree of the vertical deviation (as, for example, with overaction of an inferior oblique muscle). It also should be differentiated from an intermittent vertical strabismus which appears with fatigue. In such cases, if one performs a red glass test, or a Lancaster red-green test, the dissociated image is seen either up or down depending upon which eye is fixing-whereas in dissociated vertical divergence the dissociated image is always displaced in the same direction, no matter which eye is embarrassed. This phenomenon, although unsteady and variable on repeated testing, does not notably alter in different directions of gaze. The Heimann-Bielschowsky phenomenon pattern is usually a very small oscillation. It has been studied by electronystagmography by more recent authors as will be noted. However, a point to be emphasized here is that oscillations of only 2-3 or 4-5 degrees in a poorly seeing eye might be easily missed, or if noted, disregarded. The point of this paper is that cases may be seen in which the movements of the eye in a vertical plane may be of extremely large amplitude (from 15-20 degrees up to 50-60 degrees at times), and in such cases they are clinically striking and can be confused with a neurologic motility pattern. Dufour" et al. reported on electronystagmography in two cases of monocular nystagmus. The first was an ll-year-old boy with monocular amblyopia secondary to hypermetropic astigmatism with a high degree of anisometropia. The parents had noted oscillations of his left eye since he was an infant, and his general and neurologic history were otherwise unremarkable. The second case was a 4-year-old girl again with an unimpressive general or family history, and also with hypermetropic astigmia and an amblyopic eye. Professor Dufour described the nystagmus in these cases as having a pendular form, with a regular rhythm, and a frequency varying between 4-6/second, and noted that the movements were most frequentlv seen in the vertical plane, although some horizont,ll movements could also be seen at times. The first case had a frequency of 5/second with amplitude of 2-3 degrees, and the second case was 5-b/ second with a small amplitude of 2-3 degrees. Professor Dufour summarized the principal characteristics of this nystagmus as follows: 1) associated with notable refractive errors; 2) app,uently from the first months of life, but in the second case the parents could not precisely define the onset; 3) the nystagmus was pendular with ,1 regular rhythm and a frequency of 5-6 cyclesjsecond; 4) it was not influenced by darkness with the eyes covered; 5) it was inhibited by fixation; and 6) optokinetic and cold caloric stimulation modified the nystagmus in a variable degree. Yee et al. 7 reported on uniocular nystagmus in monocular visual loss. They studied 10 patients 89 Heim.lnn-Bielschowsky Phenomenon with monocular visual loss cJused by ocular .md optic nerve lesions with e1ectrooculogrJphy. The vision loss WJS congenital or acquired in childhood or Jdult life in these CJses. In .III pJtients the oscillJtions were present in the primary position of gJze-and were vertical, pendulJr, of variJble dnd low frequency (less thJn or equJI to I cycle/second), dnd the dmplitude WdS usudlly less thdn 5 degrees. Refixdtion SJccJdes, smooth pursuit, optokinetic nystdgmus, and vestibulooculdr responses to horizontdl and verticdl rotdtion were .111 found to be within normJI limits. The irregulJrity, low frequency, and low dmplitude of this form of nystdgmus were emphasized dS cdusing it to be often missed on CJsudl c1inicdl eXdmindtion, but dllowed it to be differentidted from other Cd uses of uniocular nystdgmus. The reference to Dr. Heimann's paper was obtained from Dr. Yee's important paper, and is gratefully acknowledged here. Yee et .II.' documented a very important point in their report. They maintained that the visual loss resulting in uniocular nystagmus was severe in all of their patients, but it was not necessarily permanent. Their case 10 was a patient with a mature presenile cataract of the left eye with uniocular nystagmus with onset of vision loss in adulthood. After cataract surgery and aphakic correction with a contact lens in the left eye, the nystagmus disappeared! This is a critically important observation in confirming the fact that the eye movements in question are integrally related to the visual sensory deficit and promptly disappear with its correction. This is reminiscent of the observation of the disappearance of periodic alternating nystagmus associated with Terson's syndrome immediately following visual restoration by vitrectomy as recently reported by Cross et al.M Finally, it should be noted that Dr. Yee observed nine of his 10 cases within a 6-month period in a general eye clinic. This shows that small degrees of the phenomenon are really not infrequent if looked for, and the appreciation of them will lead the clinician to be able to detect the more notable amplitudes of excursion as seen in the cases presented here. An important neurologic point is that it is critical to differentiate this motility disorder in small children from spasmus nutans and from dissociated nystdgmus reminiscent of spasmus nutans that c.m be either a congenitdl nystagmus or a more ominous see-saw variant seen with certain forms of brain tumors near the third ventricle and chiJsm region. We recommend .1 high-qudlity thin resolution computed tOlTl9graphic brain scan in .lll infants suspected of having spasmus nutans at this time. This is because spasmus nutans is extremely rare in our department dnd nystagmus seen with childhood brdin tumors (dS optic gliomas) is definitely more frequent, .lOd it is imperdtive thdt these not be over!clllked. Finally, we discuss the management of the uniocular vertical oscillations of amblyopia. Case 3 presented with the vertical oscillations as a cosmetic chief complaint. Dr. Flynn noted that the movements were greater in a downward direction than in an upward one (this was also present in case 1). A faden operation on the inferior rectus muscle was placed in that patient. Following surgery, the vertical oscillations were definitely improved. It cannot be stated definitely that the faden procedure was the only factor in improvement in that patient, because a lateral rectus recession on an adjustable suture was also performed. It should be noted that Heimann commented on improvement in a case after horizontal muscle surgery in 1902. A physician from Scandinavia wrote that he had a patient distressed by large vertical ocular oscillations that were ocular myoclonus following a brain stem lesion, and that the patient had great difficulty in reading, eating, and walking because of vertical oscillopsia. After discussing our result with case 3 in this paper, that physician performed a vertical faden operation on all four vertical rectus muscles of his patient, and later wrote that the patient had a definite dampening of the vertical eye movements and a subsequent improvement in reading visual acuity. The question of such surgery for other vertical motility disorders (such as intractable downbeat nystagmus and vertical ocular myoclonus) can be raised. We do not have the answer to that question as yet. Dr. Flynn performed faden surgery on a single patient with downbeat nystagmus with no significant improvement. However, the improvement of case 3 by muscle surgery was documented in this report, and finally it was though prudent to emphasize this interesting ocular motility pattern to the ophthalmological and neurological community. References I. Heimann. E.: Einseitiger Nystagmus. KJin. Monatsbl. Augenheilkd. 49: 99-105, 1902. 2. Bielschowsky, A.: Die einseitigen und gegensinnigen ("dissoziierten") vertikalbewegungen der augen. Arch.Ophtha/mol. 125: 493-553,1931. 3. Bielschowsky, A.: Lectures on Motor Anomalies. Dartmouth College Publications, Hanover, N.H., 1940. 4. Duke-Elder, S.: Textbook of Ophthalmology, Vol. 4. Henry Kimpton, london, 1949. pp. 4177-4180. 5. Walsh, T./., and Smith, J.l.: Sarcoidosis and suprasellar mass. In Univ. Miami Neuro-ophthalm%gy Symposium, Vol. 4. C.V. Mosby Co., St. louis, 1968. pp. 167-177, chapter 12. c. Dufour, A. et al.: Considerations electronystagmographiques sur deux cas de nystagmus monoculaire. Rev. Otoneuroophtalmol. 44: 125-132, 1972. 7. Yee, R.D., et .11.: Uniocular nystagmus in monocular visual loss. Ophthalmology 86: 511-518, 1979. Journal of Clinical Neuro-ophthalmology B. Cross, S.. et .ll.: Periodic .lltern.lting nyst,lgmlls de,lring ,lfter vitredomy. /. Clin. Nellfl1-ophth,1Irllll/ 2: 5-11, 1082. Acknowledgments Gr.lteful .lcknowledgment is given III Mrs. Cindy I'ritch, ud, ortht'ptist h'r electn>nyst.lgnlllgr,lphil reulrds, June 1982 Smith, Flynn, Spin> Mr. Fern.lndo Conzdlez for cinem.ltogr.lphy, Miss BMb. lr.l French for help with slides dnd prints, .lnd Mrs. Rev.l Hurtes .lnd Mrs. DonnJ Higgs for ref('rence help. Write for reprints to: I. L. Smith, MD., BJscom Palmer [ye Institute, 1'. O. Box 016880, Mi.lmi, Florid.! 33101. 91 |
