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1 Chiari Malformation Causing Downbeat Nystagmus in Lateral GazeThis is a 20-yo-man who presented with oscillopsia in lateral gaze from downbeat nystagmus (DBN). In primary gaze, very subtle DBN was only noted with ophthalmoscopy, but in lateral gaze, prominent DBN was present. Other central ocular motor signs included gaze-evoked nystagmus (GEN) vertically, in ...Image/MovingImage
2 Convergence Insufficiency and Square Wave Jerks in PSPThis is a 70-yo-woman with progressive supranuclear palsy with complaints of difficulty reading. Her husband noticed that she would frequently close one eye when attempting to read, and words were not clear on the page, and this would in fact improve by covering one eye. On her exam, she had a 1 pri...Image/MovingImage
3 Downbeat (Perverted) Head Shaking Nystagmus in a Patient with Spontaneous Torsional NystagmusThis is a 75-year-old woman with vascular risk factors who experienced abrupt onset imbalance and dizziness. Symptoms were maximal at onset, and she denied progression over 6 months. Clinically, it was felt that she had suffered a stroke, although an MRI one months later demonstrated an unremarkable...Image/MovingImage
4 Dix-Hallpike Maneuver in Posterior BPPV with Reversal of Nystagmus on Sitting UpThis is a patient with typical posterior canal (PC) benign paroxysmal positional vertigo (BPPV), which is provoked by the Dix-Hallpike maneuver. When the patient is moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) nys...Image/MovingImage
5 Downbeat Nystagmus and Cerebellar AtrophyThis is a 40-year-old man with 2 years of progressive ataxia and oscillopsia. On examination, he had downbeat nystagmus (DBN), an ocular motor finding that is usually (but not always) associated with flocculus/paraflocculus dysfunction, which causes overaction of the anterior canal (upward or anti-g...Image/MovingImage
6 Dynamic Visual AcuityAfter assessing static binocular visual acuity, dynamic visual acuity (DVA) is determined by repeating the test during horizontal and vertical head shaking at 2-3 Hz. Dynamic visual acuity is most important to test when bilateral vestibular loss is suspected. A loss of at least 4 lines is typical ...Image/MovingImage
7 Medial Longitudinal Fasciculus Syndrome with Prominent Spontaneous NystagmusThis is a 60-year-old man who experienced the abrupt onset of diplopia and imbalance. He had typical features of a left medial longitudinal fasciculus (MLF) syndrome including left internuclear ophthalmoplegia (INO) and left hypertropia from skew deviation, but he also had very prominent upbeat-tors...Image/MovingImage
8 Mild 6th Nerve Palsy Due to Pontine StrokeThis is a 70-year-old woman with HTN and diabetes who presented with horizontal diplopia for several weeks, worse in right gaze. There was a very subtle abduction paresis OD with full motility elsewhere. With cover-uncover testing, there was a small esotropia in right gaze (esodeviation seen with al...Image/MovingImage
9 The Episodic Vestibular SyndromeThis is a 55-year-old man with 6 months of episodic vertigo without clear triggers/provocative factors, with each of his 3 previous episodes lasting less than 5 minutes. While in the clinic, he had one of his typical vertigo attacks. There was initially 30 seconds of right-beating-torsional nystagmu...Image/MovingImage
10 Oculopalatal Tremor with Prominent Nystagmus, Bilateral Horizontal Gaze Palsy, and Bilateral Facial PalsiesThis 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 facial colliculus) were demonstrated by MRI. Five years after her initial presentation she developed recurrent r...Image/MovingImage
11 One-and-a-Half Syndrome Due to Pontine HemorrhageThis is a 50-year-old woman who, while exercising in the gym, suddenly experienced vertigo, nausea, vomiting, tingling in the left arm, and diplopia. MRI demonstrated a brainstem hemorrhage that involved the right greater than left pons. Examination demonstrated a right horizontal gaze palsy due to ...Image/MovingImage
12 Optokinetic NystagmusDuring the bedside evaluation of optokinetic nystagmus (OKN), the patient is instructed to look at each red (or white) square as it moves past. Because this is not a full-field visual stimuli, using an optokinetic flag mainly allows the examiner to quickly evaluate for right/left and up/down symmet...Image/MovingImage
13 Provocative Maneuvers (Removal of Fixation, Vibration, Head-Shaking) to Accentuate Peripheral Vestibular Nystagmus)With an acute destructive process like vestibular neuritis that causes significant unilateral vestibular loss, spontaneous nystagmus is always present. However, over days to months, spontaneous nystagmus should resolve completely. In a patient with vestibular neuritis involving the right side, left-...Image/MovingImage
14 Posterior Canal BPPV Treated with Semont ManeuverThis is a patient with left posterior canal (PC) benign paroxysmal positional vertigo (BPPV), and upbeat-torsional (towards the left ear) nystagmus was provoked by left Dix-Hallpike maneuver and left side-lying maneuver. This video demonstrates treatment of her left PC BPPV with the Semont maneuver....Image/MovingImage
15 Pressure Testing for Superior Canal Dehiscence SyndromeSuperior semicircular canal dehiscence syndrome (SCDS) is caused by a third mobile window in the inner ear. This allows for transmission of sound or pressure to the superior canal. Tragal compression and/or glottic and pinched nose Valsalva may provoke vertigo and vertical-torsional nystagmus in t...Image/MovingImage
16 Pendular, Gaze-Evoked and Abducting Nystagmus in MSThis is a 40-year-old woman with a history of multiple sclerosis who presented for oscillopsia. On examination, she had bilateral internuclear ophthalmoplegia (INO-adduction lag OU and abducting nystagmus OU), with a corresponding exotropia that increased in right and left gaze. She also had horiz...Image/MovingImage
17 Posterior Canal BPPV Pre- and Post-Epley ManeuverThis is a patient with typical right posterior canal benign paroxysmal positional vertigo (BPPV), which was provoked by the Dix-Hallpike maneuver. When the patient was moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) ...Image/MovingImage
18 Pendular Nystagmus and Ocular Motor Signs in MSThis is a 30-year-old man with a 15 year history of multiple sclerosis. For the last 12 months, he experienced horizontal oscillopsia. On examination, there were ocular motor abnormalities including gaze-evoked nystagmus, saccadic smooth pursuit, and hypermetric saccades which were attributable to h...Image/MovingImage
19 Periodic Alternating Nystagmus Due to Nodulus StrokeThis 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...Image/MovingImage
20 Peripheral (Vestibular) and Central (Gaze-Evoked) Patterns of Nystagmus in a Single PatientA 55-year-old man experienced episodic vertigo and was diagnosed with Meniere's disease affecting the left ear (based on audiograms and his clinical course) about 1 year prior to presentation. About 6 months prior to presentation, intratympanic (IT) gentamicin was injected into the left ear, at whic...Image/MovingImage
21 Paraneoplastic Downbeat Nystagmus and Cerebellar Ataxia Due to Small Cell Lung CarcinomaThis is a 61-year-old woman (non-smoker) who developed a gait disorder, dizziness and oscillopsia that was progressive over 2 months. Exam demonstrated spontaneous downbeat nystagmus with side pocket nystagmus in lateral gaze (a combination of horizontal gaze-evoked and downbeat nystagmus, giving an...Image/MovingImage
22 Trigeminal Neuropathy with Loss of the Corneal ReflexThis is a woman who underwent radiofrequency ablation for left trigeminal neuralgia. Examination demonstrated loss of facial sensation on the left in addition to an absent corneal reflex on the left, consistent with involvement of the V1 (ophthalmic) branch of the trigeminal nerve. When the cornea i...Image/MovingImage
23 Trigeminal Motor Neuropathy with Weakness and Atrophy of the Muscles of MasticationThis is a man who was diagnosed with polio in childhood, which involved the motor (VIII) division of the right trigeminal nerve. The motor portion of the trigeminal nerve innervates the muscles of mastication (temporalis, masseter - both of which demonstrate wasting in this patient - as well as the ...Image/MovingImage
24 Subtle Torsional Pendular Nystagmus in Oculopalatal Tremor (OPT)This 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 ...Image/MovingImage
25 Spontaneous Upbeat Nystagmus in Acute Wernicke's EncephalopathyThis is a 40-year-old woman presenting with imbalance, confusion and oscillopsia. Exam demonstrated upbeat nystagmus (UBN) in primary gaze that remained UB in all directions of gaze, with a slight torsional component (top poles beating toward right ear) in certain directions of gaze. Her nystagmus f...Image/MovingImage
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