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TitleDescriptionType
126 Maddox Rod and Red Glass TestingStrabismus basics
127 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...
128 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
129 Triangle of Guillain-MollaretSeen here is a schematic representation of the Gullain-Mollaret triangle (Figure 1), also referred to as the dentato-olivary pathway, reflecting the 3 points of this imaginary triangle - 1) dentate nucleus, 2) red nucleus, and 3) inferior olivary nucleus. The olive sends decussating climbing fibers ...
130 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 ...
131 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 ...
132 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
133 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
134 Semicircular pathwaysOnce the semicircular canal fibers leave the peripheral labyrinth, they synapse in the ipsilateral vestibular nucleus, and then ascend to the ocular motor nuclei. This enables the vestibulo-ocular reflex to respond to head movements in the plane of any canal or combination of canals.
135 Saccadic hypermetria and ipsipulsion (behind closed eyelids and with vertical saccades)This is a 40-year-old woman who experienced oscillopsia and vertical diplopia, due to spontaneous torsional nystagmus and a skew deviation (right hypotropia), respectively. The symptom onset was 7 months prior to these videos. MRI demonstrated ill-defined T2 and FLAIR hyperintensity signal changes i...
136 Alternating hypertropias - bilateral 4th nerve palsies and alternating skew deviationSeen here are two patients with alternating hypertropias. The first is a 70-year-old woman with a diagnosis of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). In the video, both spontaneous downbeat nystagmus (DBN) and gaze-evoked nystagmus (GEN) are apparent, in addition to a...
137 Gaze-evoked and centripetal nystagmus in Creutzfeldt-Jakob diseaseThis is a 65-year-old woman who experienced a progressive cerebellopathy over several months. Initially, she presented with mild gait imbalance and positional vertigo, and there was only apogeotropic positional nystagmus (more pronounced in supine roll test compared to Dix-Hallpike) with a very slig...
138 Test Your Knowledge - Ocular tilt reaction and subjective visual verticalLesions of which of the following neuro-anatomic structures could result in the clinical findings shown? A. Right medulla B. Right interstitial nucleus of Cajal C. Right medial longitudinal fasciculus D. Left trochlear nerve E. Right caudal midbrain A. Correct. This patient presents with elements...
139 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
140 3rd nerve palsy with preserved 4th nerve function80-yo-woman with a left vasculopathic 3rd nerve palsy (minimal pupil involvement of about 1 mm relative mydriasis OS - other etiologies ruled out and resolved as expected over months). Although the inferior rectus is paretic, intact superior oblique muscle function can be demonstrated by asking the ...Image/MovingImage
141 Elliptical Pendular Nystagmus in MSThis is a 40-yo-woman with MS and bilateral optic nerve disease who presented with a year's long history of oscillopsia, which was related to elliptical pendular nystagmus. The appearance of elliptical nystagmus is the result of out of phase horizontal and vertical components. She had a variety of p...Image/MovingImage
142 Bilateral INOs and partial 3rd nerve palsiesThis is a 45-year-old man with progressive ptosis and ophthalmoparesis. 10 years prior to presentation, he experienced diplopia and had a hyperintense lesion involving the medial longitudinal fasciculus (MLF) per report. Over time, he developed bilateral adduction paresis, ptosis and upgaze paresis ...
143 Bilateral pseudo-abducens palsies due to midbrain strokeThis is a man who suffered right>left midbrain strokes due to endocarditis complaining of ptosis and inability to move his eyes as well as hallucinations (peduncular hallucinosis). There was a presumed nuclear 3rd nerve palsy on the right (i.e., responsible for his mydriatic pupil, absent supra- and...Image/MovingImage
144 Central 4th nerve palsy with contralateral Horner's syndromeThis is a 60-yo-woman who presented with a complaint of diplopia. Examination demonstrated a left hypertropia that worsened in right and down gaze as well as in left head tilt, and a left 4th nerve palsy was diagnosed. There was also evidence of a mild motility deficit in down/medial gaze OS, consis...Image/MovingImage
145 Anti-GAD associated cerebellopathy and bilateral vestibulopathyThis is a 70-year-old woman with the subacute onset of severe imbalance and dizziness. On her initial examination, she had prominent gaze-evoked nystagmus and bilateral vestibular loss. Smooth pursuit was saccadic, although her vestibulo-ocular reflex (VOR) suppression was much smoother. Usually pur...
146 Ocular motor signs in SCA 6This is a 45-yo-man who was recently diagnosed with SCA 6. There was no clear spontaneous downbeat nystagmus (DBN) in primary gaze, although DBN could clearly be provoked by convergence. Other ocular motor features included choppy pursuit and VOR suppression horizontally and vertically, in addition ...
147 Sagging eye syndrome and cerebellar disease in divergence insufficiencyThis is a 70-year-old woman who presented with diplopia at distance. Her exam demonstrated orthophoria at near with a fairly comitant 8-10 PD esotropia at distance without abduction paresis, consistent with divergence insufficiency (DI). With age, patients may develop an esodeviation greater at dist...
148 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...
149 Pseudo-spontaneous nystagmus and bow and lean test in horizontal canal BPPVThis is a 70-year-old woman presenting to the Emergency Department with positional vertigo that was determined to be due to the apogeotropic variant of right horizontal canal (HC) benign paroxysmal positional vertigo (BPPV). When her head is in a neutral position with the head in axis with the trunk...
150 Bilateral 6th nerve palsies due to idiopathic intracranial hypertensionThis is a 25-year-old woman who presented with diplopia and blurry vision. On exam, she was found to have papilledema and bilateral 6th nerve palsies. Her opening pressure was >40 cm of water with a normal CSF analysis, and neuroimaging was unremarkable aside from subtle findings that have been asso...
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