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151 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 - ...Saccades; Exam; Conjugacy; Abnormal saccades
152 Saccadic dysmetria and ocular lateropulsion in lateral medullary strokeThis is a 30-yo-man who suffered a right lateral medullary stroke. Examination showed saccadic hypermetria to the right (ipsilesional), hypometria to the left (contralesional)and rightward ocular lateropulsion (ipsilesional), common ocular motor features of the lateral medullary syndrome. Saccadic h...Lateral medullary syndrome, Wallenberg Syndrome, Saccadic dysmetria, Ocular lateropulsion, Saccades
153 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...Jerk nystagmus; Torsional nystagmus; Saccades; Lateropulsion; Medulla
154 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 ...Square Wave Jerks
155 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
156 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
157 Saccadic smooth pursuit and vestibulo-ocular reflex suppression (VORS)This is a 20-yo-man who suffered a left MCA stroke years prior. Upon evaluation of his eye movements, saccades and all classes of eye movements were normal, although his smooth pursuit and VORS were choppy to the left (ipsilesional) and normal to the right. When pursuit and VORS (which are usually e...Smooth pursuit; Vestibulo-ocular reflex (VOR) supression
158 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...Abnormal Alignment, OMS Cerebellar, Jerk Nystagmus, Gaze Evoked Nystagmus, Divergence Insufficiency
159 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
160 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
161 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.Vestibulo-ocular reflex
162 Sequelae of cerebellar hemorrhage - gaze-evoked nystagmus, alternating skew deviation and palatal tremorThis is a 75-yo-woman presenting with a gait disorder. Two years prior, she suffered a cerebellar hemorrhage. On examination, there were typical cerebellar ocular motor signs including gaze-evoked nystagmus, choppy smooth pursuit and VOR suppression, and saccadic dysmetria. There was also an alterna...Assessing Abnormal Alignment, Jerk Nystagmus, Gaze Evoked Nystagmus, Oculopalatal Myoclonus
163 Sequential vasculopathic 3rd nerve palsies with preserved 4th nerve function65-yo-man with uncontrolled diabetes who developed sequential vasculopathic 3rd nerve palsies. In attempted downgaze, there's clear incyclotorsion OU suggestive of preserved 4th nerve function on both sides. There was complete recovery over months. Video shows bilateral 3rd nerve palsies with intact...Third (Oculomotor) Nerve Palsy; Third subnuclear
164 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...Abnormal Alignment, Jerk Nystagmus, Upbeat Nystagmus, Vestibular Nystagmus, Rotary Nystagmus, Skew Deviation
165 Slow abducting saccade in 6th nerve palsy40-yo-man with a right fascicular 6th nerve palsy due to stroke. There was improvement and only a minimal residual right abduction paresis OD by this visit, but still a relatively slow right abducting saccade seen in the video, especially apparent in the slow motion segment. Video shows slow abduct...Sixth (Abducens) Nerve Palsy; Abnormal Saccades
166 Slow saccades due to unilateral paramedian pontine reticular formation (PPRF) injury with preserved movements using the vestibulo-ocular reflexThis is a 60-year-old man who presented for imbalance and oscillopsia 10 months after surgery and 8 months after radiation for Merkel cell carcinoma of the neck. He developed imbalance after surgery and diplopia and oscillopsia 6 months prior to our evaluation. MRI showed enhancement of both 6th n...Abnormal Saccades, Pons OMS, Sixth Abducens Nerve, Abnormal VOR, Vestibulocochlear Nerve, Horizontal Gaze Palsy
167 Slow volitional saccades and poor fast phases to an optokinetic stimulus, with preserved head impulse testingThis is a 67-year-old woman presenting with imbalance and binocular horizontal diplopia at near. On examination there were frequent square wave jerks, limited supraduction OU and convergence insufficiency, which explained her diplopia. Pursuit and suppression of the vestibulo-ocular reflex were sa...Abnormal Saccades, VOR HIT Normal
168 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 lesionsPursuit, Exam
169 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...Upbeat Nystagmus, Jerk Nystagmus, Medullar OMS
170 Square wave jerks and macrosaccadic oscillations in a patient with a cerebellar tumorThis is a 40-year-old man who developed severe headaches, confusion, and gait imbalance which led to neuroimaging which demonstrated a midline cerebellar mass with compression of the fourth ventricle and obstructive hydrocephalus. He underwent a suboccipital craniectomy for resection of the mass, an...Abnormal Saccades, Square Wave Jerks
171 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 ...Pendular Nystagmus; Oculopalatal Tremor
172 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
173 Summary of the most common audio-vestibular testingChart describing common audio-vestibular testing.Vestibular lab testing
174 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...Nystagmus; Superior canal dehiscence; Valsalva
175 Superior Oblique Myokymia (SOM)This is a patient with transient monocular oscillopsia OD and vertical diplopia noted to have many episodes of SOM in the office. There was not only myokymia OD, but also a 4 prism diopter left hypertropia during episodes (suggestive of mild depression OD from SO activation). Ocular motor and alignm...Superior oblique myokymia; Transient monocular oscillopsia; Vertical diplopia
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