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1 A Comparison of Nystagmus and Saccadic Intrusions/OscillationsNystagmus can be classified into pendular and jerk waveforms, where both are generated by a slow, pathologic phase. Corrective phase (the position reset mechanism) differs. In pendular nystagmus, the eyes move back and forth with about the same velocity and amplitude, similar to that of a pendulum...Jerk Nystagmus, Flutter, Pendular Nystagmus, Square Wave Jerks, Opsoclonus,
2 Brainstem ocular motor machinerySeen here is a sagittal view of the brainstem. The medulla has a significant role in gaze-holding, and the nucleus prepositus hypoglossi (NPH, along with the medial vestibular nucleus ) is the horizontal neural integrator. The abducens (6th) nucleus is located in the dorsal pons, and sends off the 6...Medulla OMS, Pons OMS, Mesencephalon OMS, Dorsal Midbrain OMS
3 Central anatomy of the IIIrd nerveSeen here is an axial section of the midbrain at the level of the superior colliculus. The paired nuclei are located ventral to the periaqueductal grey, and the midline central caudal nucleus (CCN) is located between the right and left nuclei. The CCN sends projections to bilateral levator palpebrae...Mesencephalon, Figures, Third Nerve Palsy
4 Central anatomy of the IVth nerveThe IVth or trochlear nucleus is located ventral to the central periaqueductal grey matter, dorsal to the medial longitudinal fasciculus (MLF) and medial to the oculosympathetic tract at the level of the inferior colliculus. The fascicles of the IVth nerve travel dorsally and caudally around the cen...Figures; Mesencephalon OMS
5 Coronal section of the brainstem showing ocular motor nuclei and anatomy of the vestibular nucleus (with SCC inputs)(A) Seen here is a coronal view of the brainstem showing the locations of the ocular motor nuclei (IIIrd, IVth, VIth) as well as the nuclei of VII and VIII (vestibular and cochlear). The vestibular nucleus (VN) is divided into the inferior, lateral, medial, and superior subnuclei, and the medial ves...Pons, Medullar OMS, Mesencephalon OMS, figures
6 Eyelid anatomySeen here are the major muscles of eyelid opening and closure. The levator palpebrae, which is innervated by the oculomotor nerve, inserts on the tarsus via the levator aponeurosis and directly on the skin of the upper eyelid. The superior tarsal muscle (also known as Muller's muscle, which is inner...Figures
7 Medullary structures relevant to the ocular motor and vestibular consequences of lateral medullary (Wallenberg) syndromeThis is an axial section of the medulla showing the structures that, when damaged, are responsible for the vestibular and ocular motor features of the lateral medullary or Wallenberg syndrome. The nucleus prepositus hypoglossi (NPH) and medial vestibular nucleus (MVN) complex is important for horizo...Medulla OMS; figures
8 Medullary structures relevant to upbeat nystagmusThis is an axial section of the medulla, slightly more caudal as compared to (please refer to figure "medullary structures relevant to the ocular motor and vestibular consequences of the lateral medullary (Wallenberg) syndrome). Again seen are the inferior cerebellar peduncle (ICP) and caudal aspect...Medulla OMS; figures
9 Neuro-ophthalmic features and pseudo-MG lid signs in Miller Fisher syndrome - Figure 1This is a 51-year-old woman who presented with imbalance, acute onset dizziness and diplopia that developed over three days following two weeks of upper respiratory infection and bacterial conjunctivitis. When she was initially seen as an outpatient, nystagmus was noted to the right and left, and a ...Abnormal VOR, Miller Fisher Syndrome, Myasthenia Gravis, Acute Vestibular Syndrome, Jerk Nystagmus, Gaze Evoked Nystagmus
10 Ocular motor & vestibular features of the MLF syndrome - Figures 1, 2, and 3This 61-year-old woman with HTN and DM presented for evaluation of acute onset diagonal diplopia. Adduction OS was about 60% of normal while medialization OS improved with convergence. In right gaze, dissociated abducting nystagmus was present OD, and there was a clear adduction lag when asking he...INO, Jerk Nystagmus, Torsional Nystagmus, Gaze-evoked Nystagmus
11 Oculopalatal tremor with prominent nystagmus, bilateral horizontal gaze palsy, and bilateral facial palsies Figure 1Figure 1, MRI T2 sequence demonstrating hyperintensities involving bilateral inferior olives of the medulla. This is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facia...Abnormal Range, Sixth Nerve Palsy, Facial Nerve, Horizontal Gaze Palsy, OMS Pons, Pendular Nystagmus, Oculopalatal
12 Periodic alternating nystagmus due to nodulus stroke - Figure 1This is a 70-year-old woman who experienced the acute onset of vertigo and imbalance. MRI demonstrated a diffusion-weighted imaging hyperintensity involving the nodulus (with corresponding ADC hypointensity) consistent with an acute stroke. On examination several weeks after the stroke, periodic alt...Periodic Alternating Nystagmus, Jerk Nystagmus
13 Pons: 6th and 7th nerve anatomy and the central tegmental tractFrom this cross-section of the pons, the proximity of the 6th nucleus to the 7th nerve fascicles is apparent. This is the basis of the so-called facial colliculus syndrome, where an ipsilesional horizontal gaze palsy from a nuclear 6th lesion (usually related to stroke or demyelination) can be seen ...Sixth Nerve Palsy, INO, One and a Half, Horizontal Gaze Palsy, OMS Pons, Facial Nerve, Oculopalatal
14 Pons: 6th, 7th, 8th, and middle cerebellar peduncle anatomyFrom this cross-section of the pons, the proximity of the 7th and 8th fascicles can be appreciated, and a lateral inferior pontine syndrome (anterior inferior cerebellar artery territory), which could involve both of these fascicles, could cause acute prolonged vertigo accompanied by a + ipsilateral...Sixth Nerve Palsy, OMS Pons, Facial Nerve, VOR Normal, VOR Abnormal
15 Relationship between semicircular canals and extraocular musclesFigure 1: When stimulated, each of the 6 angular acceleration detecting semicircular canals (3 on the right and 3 on the left) responds with a conjugate eye movement, with the vector(s) indicated below. PC=posterior canal; HC=horizontal (also known as lateral) canal; AC=anterior (also known as super...Extraocular Muscles
16 Saccadic pathways in the brainstem and cerebellum & mechanism for saccadic dysmetria in Wallenberg syndrome - Abnormal function of the brainstem/cerebellar saccadic pathways with a left Wallenberg syndromeThe end result of a lesion involving the climbing fibers within the left lateral medulla is deficient rightward saccades (contralesional hypometric saccades), and over-active leftward saccades (ipsilesional hypermetric saccades), and ipsilesional ocular lateropulsion given this baseline imbalance. M...Medulla OMS, Normal Saccades, Abnormal Saccades, Figures
17 Saccadic pathways in the brainstem and cerebellum & mechanism for saccadic dysmetria in Wallenberg syndrome - Normal function of the brainstem/cerebellar saccadic pathwaysThe inferior cerebellar peduncle (ICP) carries climbing fibers to the dorsal vermis, and these fibers have an inhibitory influence over the Purkinje cells. These Purkinje cells normally inhibit the ipsilateral fastigial nucleus, and the fastigial nucleus projects to the contralateral inhibitory burs...Medulla OMS, Normal Saccades, Abnormal Saccades, Figures
18 Sagittal section of the brainstem showing structures related to normal eyelid functionSeen here is a sagittal view of the brainstem, with the structures relevant to normal eyelid function highlighted. The M-group, which can be found medial to the riMLF (coordinates eye and lid movements), has (weak) projections to the facial nucleus for frontalis muscle contraction, and (strong) proj...Figures; Mesencephalon OMS
19 Sagittal section of the midbrain showing structures related to normal eyelid functionDuring a vertical saccade, the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) is activated, which excites the superior rectus (SR) and inferior oblique (IO) (IIIrd nerve) subnuclei. Additionally, the riMLF activates the nearby M-group. The M-group's primary excitatory out...Figures; Mesencephalon OMS
20 Subtle torsional pendular nystagmus in oculopalatal tremor (OPT) - Figure 1This is a 50-year-old woman who presented with imbalance, and MRI demonstrated a right cerebellar cavernous malformation. She underwent surgery to resect the malformation, and post-operatively experienced right hemiparesis and ataxia. Six months after the surgery, balance worsened and vision became ...Pendular Nystagmus; Oculopalatal Tremor
21 The most common audiovestibular laboratory tests, and the specific conditions in which they may assist in making or supporting the diagnosisVN = vestibular neuritis; VM = vestibular migraine; VP = vestibular paroxysmia; vHIT = video head impulse test; VNG = video-nystagmography; ENG = electronystagmography; VOG = video-oculography; VEMPs = vestibular evoked myogenic potentials; SCDS = superior canal dehiscence syndrome; BPPV = benign pa...Vestibular Examination, Vestibular Lab Testing
22 The most common vestibular conditions categorized by timing and triggers, with specific historical features that should be sought for each (adapted from Approach to the Ocular Motor and Vestibular History and Examination)BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual dizziness; MDDS = Mal de debarquement syndromeSummary and Review
23 The most common vestibular conditions categorized by timing and triggers, with specific ocular motor and vestibular features that should be sought for eachHINTS+ = Head Impulse, Nystagmus, Test of Skew, ‘Plus' bedside assessment of auditory function; HIT = head impulse test; NP = nerve palsy; BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual ...Vestibular Examination
24 The utriculo-ocular motor pathways - physiologic and pathologic ocular tilt reaction: OTR Diagram Pathologic EOMs Labelled (Figure 3)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...Skew Deviation
25 The utriculo-ocular motor pathways - physiologic and pathologic ocular tilt reaction: Pathologic OTR (Figure 2)A skew deviation is a non-paralytic vertical ocular misalignment that is due to imbalance in the utriculo-ocular motor pathways. While vestibular jerk nystagmus is a consequence of static semicircular canal pathway imbalance (e.g., left-beating nystagmus due to acute right vestibular hypofunction fr...Skew Deviation
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