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126 Ocular motor & vestibular features of the MLF syndromeThis 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...video/mp4
127 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...image/jpeg
128 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...video/mp4
129 Testing for adduction lag in partial INO using an optokinetic stimulusIn this patient we demonstrate the use of an optokinetic stimulus to elicit an internuclear ophthalmoplegia (INO). Occasionally adduction appears to be normal with an INO, and an adduction lag with horizontal saccades should be sought as a confirmatory sign. Optokinetic tape is an easy way to assess...video/mp4
130 Test Your Knowledge - Monocular OscillopsiaWhich of the following associated signs is most likely to be seen in this patient presenting with oscillopsia? ; A.; Optic nerve pallor ; B.; Palatal tremor; C.; Severe unilateral cataract ; D.; Head bobbing; E.; Neurovascular contact on MR CISS/FIESTA imaging; ; A.; Correct. This patient has MS an...video/mp4
131 Test Your Knowledge - The acute vestibular syndrome and ptosisWhat is the most likely localization in this patient presenting with vertical diplopia and acute onset prolonged vertigo? ; A.; Right medial longitudinal fasciculus (MLF); B.; Left medial longitudinal fasciculus ; C.; Right medulla; D.; Left medulla; E.; Left midbrain; ; A.; Incorrect. A right MLF l...video/mp4
132 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...video/mp4
133 Ocular motor signs in early progressive supranuclear palsyThis is a 64-year old man who experienced imbalance and falls (usually backwards) for the last 6 months. He experienced difficulty navigating stairs and had become a messy eater (thought to be in large part due to his vertical gaze palsy), and had developed hypophonia. Exam demonstrated square wave ...video/mp4
134 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...image/jpeg
135 Measuring Divergence AmplitudeDivergence insufficiency should be suspected in patients with binocular horizontal diplopia at distance (but not near) who lack abduction deficits. There should be an esodeviation greater at distance, and in older patients with levator dehiscence (or previous ptosis surgery) and prominent superior s...video/mp4
136 Central Acute Vestibular Syndrome due to posterior fossa hemorrhageThis is a patient presenting with the acute vestibular syndrome (AVS, e.g., acute prolonged vertigo, spontaneous nystagmus) whose HINTS (Head Impulse, Nystagmus, Test of Skew) testing indicated a central etiology based on negative (normal) head impulse testing (HIT). Nystagmus was unidirectional and...video/mp4
137 Duane's syndrome type 3This is a 40-yo-woman seen in neurology clinic for a complaint unrelated to her eyes. On exam, there was impaired adduction and abduction OS. In adduction, there was narrowing of the palpebral fissure OS, a result of her globe retraction due to co-contraction of the medial and lateral rectus muscles...video/mp4
138 ConvergenceCan bring out or change the direction of vertical nystagmus in Wernicke's, or cerebellar disease; may be impaired in Parkinson's disease, head trauma, elderly patients; may overcome an adduction deficit with an INO. Instructional ocular motor examination procedures.video/mp4
139 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...video/mp4
140 Assessing for hyperventilation-induced nystagmusHyperventilation induced nystagmus is tested by asking the patient to take quick deep breaths (~1/s) for 40-60 seconds. This increases ICP and CSF pH. This can be helpful in diagnosing irritative conditions of the vestibular nerve, including an acoustic neuroma (see video, https://collections.lib....video/mp4
141 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 ...video/mp4
142 Evaluation of ConvergenceThe assessment of convergence includes measuring alignment at near versus distance (see video, https://collections.lib.utah.edu/details?id=187677), near point of convergence and convergence amplitude. Near point of convergence is assessed by bringing a fixation target toward the bridge of the patie...video/mp4
143 Evaluation of auditory function using Rinne and Weber testsThe Rinne test is an assessment of auditory thresholds to air and bone conduction of sound. The Weber test is a comparison of bone conducted sound of either ear. Conductive hearing loss results in a loss of air conducted greater than bone conducted sound, whereas sensorineural hearing loss results...video/mp4
144 The geotropic variant of horizontal canal BPPVThis is a patient with the geotropic (nystagmus beating towards the ground) variant of left horizontal canal (HC) benign paroxysmal positional vertigo (BPPV). In a patient with geotropic (nystagmus beating towards the ground) HC BPPV, by rapidly moving from a sitting to a supine position with the he...video/mp4
145 The apogeotropic variant of horizontal canal BPPVThis is a patient with the apogeotropic (nystagmus beating towards the sky) variant of right horizontal canal (HC) benign paroxysmal positional vertigo (BPPV). In a patient with geotropic (nystagmus beating towards the ground) HC BPPV, by rapidly moving from a sitting to a supine position with the h...video/mp4
146 Ocular AlignmentThese tests allow for detection of eso-, exo- or hyperdeviations (phorias (one eye viewing) or tropias (both eyes viewing) that can be seen with ocular motor palsy, skew deviation, or with cerebellar disease (commonly esodeviation greater at distance) Instructional ocular motor examination procedure...video/mp4
147 SaccadesThe examiner should note: conjugacy (a lag of the adducting eye may be seen with an INO); accuracy (posterior fossa lesions commonly produce dysmetria (overshooting or undershooting); velocity (if slow, may suggest a lesion of the burst neurons in the pons [PPRF - horizontally] or midbrain [riMLF - ...video/mp4
148 Smooth PursuitA pursuit deficit in one direction suggests an ipsilesional localization, but beware of a superimposed spontaneous nystagmus; a pursuit deficit in all directions is commonly seen with cerebellar lesionsvideo/mp4
149 VOR (Slow and Fast)Slow vestibulo-ocular reflex (VOR): Since smooth pursuit and VOR systems are both active, if eye movements are choppy with this maneuver this implies deficits in both pursuit and the vestibular system as in CANVAS; Fast (HIT): Since smooth pursuit fails at high frequencies and high speeds, the VOR i...video/mp4
150 Skew deviation and spontaneous nystagmus due to posterior fossa lesionsThis is a 50-year-old woman who reported the abrupt onset of imbalance, right upper extremity incoordination and binocular vertical diplopia several months prior to her presentation to our clinic. On examination, she had a left hypertropia that was fairly comitant (measuring 5 prism diopters) assoc...video/mp4
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