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1 Lateral pontine stroke involving the superior vestibular nucleus causing spontaneous upbeat-torsional nystagmusA 65-year-old man presented to the emergency department with spontaneous vertigo and unsteadiness, and had was noted to have spontaneous upbeat nystagmus (UBN), also with a torsional component (top poles beating toward the right ear) that was most noticeable in right and up gaze. General neurologic ...Image/MovingImage
2 Leukemic leptomeningeal carcinomatosis causing 4th and 6th nerve palsiesThis is a 55-yo-man with CML that recurred as AML. Diagonal diplopia developed, and on examination he was found to have a partial right 6th nerve palsy, in addition to a left hypertropia that increased in right gaze, down gaze, and in left head tilt consistent with a left 4th nerve palsy. There was ...Image/MovingImage
3 Divergence insufficiency in cerebellar ataxiaThis is a 65-yo woman with complaints of imbalance (progressive over years) and horizontal diplopia at distance. On her exam, there was a small symptomatic esotropia at distance, but only a small esophoria at near. There were no obvious abduction deficits, and the 6 prism diopter ET at distance was...Image/MovingImage
4 Vertical gaze palsy and saccadic intrusions due to anti-Ri from head and neck carcinomaA 55-yo- woman was admitted for imbalance and double vision. Three weeks prior to presentation she first noticed swelling on the right side of her face and neck. CT of the head and neck showed right-sided cervical adenopathy and enlarged left retropharyngeal node. Ultrasound- guided biopsy of the n...Image/MovingImage
5 Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhageThis is a 70-yo-man who suffered a right midline thalamic/rostral midbrain hemorrhagic stroke causing a pretectal (Parinaud's) syndrome. There was prominent eyelid retraction (Collier's sign), a left pseudo-abducens, and upgaze palsy with convergence retraction nystagmus. There was no light-near dis...Image/MovingImage
6 Bilateral Horizontal Gaze Palsy and Oculopalatal Tremor Due to Pontine HemorrhageThis 70-yo-woman experienced headache and diplopia and was found to have a hemorrhage centrally within the dorsal pons. Months after the onset, the patient was seen in clinic and had no horizontal eye movements (pursuit, saccades, VOR) in either eye, suggestive of bilateral nuclear 6th nerve palsies...Image/MovingImage
7 Superior Canal DehiscenceThis is a 60-yo-man who complained of autophony (eg, hearing his own heartbeat, noting that his own voice sounded too loud) and dizziness triggered with loud noises and straining at times. With pinched-nose Valsalva maneuver, there was downbeat-torsional (towards the right ear) nystagmus, suggestive...Image/MovingImage
8 Oscillopsia and bilateral vestibular loss with gentamicin ototoxicityPatients with bilateral vestibular loss commonly experience oscillopsia with head movements, or an inability to stabilize retinal images with subsequent bouncing or jumping of the environment due to loss of vestibular function. This causes significant blurring of vision and disorientation, dizziness...Image/MovingImage
9 Monocular downbeat nystagmus due to a posterior fossa cystThis is a 40-yo-man who experienced months of imbalance and was found to have an epidermoid cyst (immediately posterior to the 4th ventricle), which was resected. Months after surgery, he experienced monocular vertical oscillopsia. On examination, there was subtle downbeat nystagmus (DBN) in the rig...Image/MovingImage
10 Upbeating and gaze-evoked nystagmus, V-pattern esotropia from bilateral 4th nerve palsiesImage/MovingImage
11 Oscillopsia: a common symptom of bilateral vestibular lossThis video is an example of what a patient with bilateral vestibular loss experiences while walking. Without a VOR, there is no mechanism to ensure retinal stability of the world with each head movement, and oscillopsia (illusion of movement of the stationary environment) is the result. Jumpy vision...Image/MovingImage
12 Saccadic intrusions with an intersaccadic intervalSeen here are patients with saccadic intrusions that have preserved intersaccadic intervals. Although square wave jerks (SWJ) are present in everyone to some degree at times, when prominent or when they interfere with vision, neurodegenerative conditions should be considered, mainly those involving ...Image/MovingImage
13 Typical features of Duane syndrome type 1This is a patient seen for vestibular complaints, who on exam, was found to have (unrelated to her vestibular symptoms) impaired abduction OS. In adduction, there was narrowing of the palpebral fissure OS, a result of globe retraction due to co-contraction of the medial and lateral rectus muscles. T...Image/MovingImage
14 Chronic progressive external ophthalmoplegia (CPEO) and cerebellar signsThis is a 60-yo-woman who initially presented with imbalance and ophthalmoparesis. Initially, there was mild horizontal gaze limitation with mild gaze-evoked nystagmus and slow saccades, and over the years, gait ataxia and dysarthria (mainly a scanning quality to her speech) developed, and her ophth...Image/MovingImage
15 Unilateral 3rd, 4th, and 6th nerve palsies due to cavernous sinus meningiomaThis is a 50-year-old woman presenting with a partial 3rd nerve palsy (mild pupil involvement), partial 6th nerve palsy, and no clear incyclotorsion with downgaze, suggestive of additional 4th nerve palsy, all on the left. With compressive lesions involving the 3rd nerve, often aberrant regeneration...Image/MovingImage
16 Positional downbeat nystagmus mimicking anterior canal BPPVAlthough positional downbeat nystagmus (pDBN) can indicate the rare anterior canal variant of benign paroxysmal positional vertigo, central mimics are common causes of pDBN. pDBN may be seen in multiple system atrophy (MSA), or seen with posterior fossa lesions, with a common example being a stroke ...Image/MovingImage
17 Eye closure and oculopalatal tremorThis patient suffered a traumatic brain injury with brainstem injury resulting in damage to Mollaret's triangle and palatal tremor. Inferior olivary hypertrophy was noted on her MRI, although no vertical and/or torsional pendular nystagmus was present even when observing closely with the ophthalmosc...Image/MovingImage
18 Vibration and hyperventilation-induced nystagmus from vestibular schwannomaThis is a 50-yo-woman with imbalance, and with fixation removed on her examination (with Frenzel goggles), there was no spontaneous nystagmus. Using a handheld vibrator to vibrate the mastoids and vertex, there was a rightward slow phase and corrective leftward fast phase (left-beating nystagmus). V...Image/MovingImage
19 Upbeat and downbeat nystagmus due to anti-VGCC antibodiesSeen here are two patients who presented with imbalance and vertical oscillopsia, the first with upbeat nystagmus, and the second with downbeat nystagmus. Both patients were found to have voltage-gated calcium channel antibodies in serum without evidence of systemic malignancy. The UBN patient had m...Image/MovingImage
20 Ocular motor signs in progressive supranuclear palsy (PSP)This is a 65-yo-woman complaining of imbalance and double vision. She had significant convergence insufficiency (and would close her right eye with near viewing), providing an explanation for her diplopia. Convergence insufficiency is very common with parkinsonism. She had bradykinesia and rigidity,...Image/MovingImage
21 Ocular bobbing due to hepatic encephalopathyThis is a 55-year-old man presented with hepatic encephalopathy, and found to have ocular bobbing. Head CT did not show any acute changes. Ocular bobbing almost always localizes to the pons, although cerebellar pathology has also (rarely) been identified as a cause. Typical bobbing consists of rhyth...Image/MovingImage
22 Abnormal visually-enhanced VOR in cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS)A 67 year old woman presented with 1 year of progressive numbness, gait instability, and oscillopsia when walking or with head movements. Examination showed excessive square-wave jerks, bilateral horizontal gaze-evoked nystagmus, impairment of the visually-enhanced vestibular ocular reflex (vVOR - s...Image/MovingImage
23 One-and-a-half syndrome, facial palsy, and nystagmus due to dorsal pontine demyelinationThis is a 16-yo-girl with oscillopsia and double vision. Exam showed inability to look to the left with either eye due to left nuclear 6th. There was also a left INO (horizontal gaze palsy + INO = one-and-a-half syndrome) from left MLF involvement and left lower motor neuron facial palsy due to fasc...Image/MovingImage
24 Trigeminal, Facial (with Aberrant Regeneration), and Vestibulocochlear Nerve Palsies Following Tumor ResectionThis is a 30-yo-woman who underwent resection of a right trigeminal schwannoma. Post-operatively, she was vertiginous with a clearly + head impulse test to the right (and spontaneous left-beating nystagmus), had lost hearing in the right ear, had no facial sensation on the right, and had a right low...Image/MovingImage
25 Central (Nuclear) 3rd Nerve PalsiesShown here are two patients with left sided midbrain pathology (hemorrhage and ischemia) which caused damage to the 3rd nucleus. Both of the patients have ipsilateral mydriasis, adduction, supra- and infraduction paresis. Ipsilateral>contralateral ptosis is also present, and localizes to the central...Image/MovingImage
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