eMedicine Specialties > Ophthalmology > Extraocular Muscles

Nystagmus, Acquired: Treatment & Medication

Author: Christopher M Bardorf, MD, MS, Ophthalmology, Children's Eye Physicians, Denver, CO
Coauthor(s): Gregory P Van Stavern, MD, FACP, Assistant Professor, Departments of Ophthalmology and Neurology, Wayne State University; Enrique Garcia-Valenzuela, MD, PhD, Clinical Assistant Professor, Department of Ophthalmology, University of Illinois Eye and Ear Infirmary; Consulting Staff, Vitreo-Retinal Surgery, Midwest Retina Consultants, SC, Parkside Center
Contributor Information and Disclosures

Updated: Aug 18, 2009

Treatment

Medical Care

  • Any medications that may be causing the nystagmus should be discontinued in conjunction with the patient's internist, neurologist, and/or pediatrician.
  • Significant refractive errors should be corrected. Contact lenses may be preferred over spectacles because the patient may continue to look through the optical center of the contact lens if a head turn secondary to the presence of a null zone exists. Although, this usually applies only to congenital nystagmus.
  • Base-out prisms (to induce convergence) can be used to treat downbeat nystagmus. Prisms may be useful prior to considering surgery for a face turn. Fresnel prisms directed with the base opposite the null zone (eg, for a right face turn with a null zone in left gaze, the prism over the right eye would be base out and a prism over the left eye would be base in). Null zones are more characteristic of congenital nystagmus; thus, prisms may not be applicable to most forms of acquired nystagmus.

Surgical Care

  • Removing the inciting etiology if possible (eg, intracranial tumors, ocular media opacities)
  • Botulinum toxin may be used to treat patients with acquired nystagmus to dampen the nystagmus and to improve visual acuity and to decrease oscillopsia.
    • The toxin may be injected into the rectus muscles (2.5 U per muscle) or may be given as a retrobulbar injection9 (10-25 U in 0.1-1 cm3).
    • Multiple injections usually are necessary as the effect of the toxin wears off.
    • Patients whose symptoms improve with botulinum toxin injection may be able to discern when the effect of the toxin begins to diminish as the symptoms may begin to recur.
    • A disadvantage of this treatment option is that botulinum toxin impairs all types of eye movement (eg, saccades, smooth pursuit).
    • Complications of toxin injection include ptosis, diplopia, and increase of nystagmus in the noninjected eye.
  • Extraocular muscle surgery for correction of nystagmus is based on surgically shifting the null zone into primary position. Again, null zones are more characteristic of congenital nystagmus; thus, they may not be applicable to most forms of acquired nystagmus. Retroequatorial rectus muscle recessions have been shown to be effective in treating acquired nystagmus without a null point.10

Consultations

  • Neurologic or neuro-ophthalmic consultation should be considered.
  • Neurosurgical or oncologic consultation should be sought in cases with a neoplastic etiology.
  • Otolaryngologic consultation should be considered in cases of benign positional vertigo or other peripheral vestibular disorders.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Muscle relaxants, GABA agonists

Use for periodic alternating nystagmus, downbeat and upbeat nystagmus, and seesaw nystagmus.11


Baclofen (Lioresal)

Periodic alternating oscillopsia may be a major complaint in patients with periodic alternating nystagmus and may be cured by the use of baclofen.

Adult

5 mg PO tid; not to exceed 80 mg qd

Pediatric

<2 years: Not established
2-8 years: 10-40 mg/d PO divided tid/qid
Start: 2.5-5 mg PO tid x 3d; increase by 5-15 mg/d q3d prn; 40 mg/d maximum
8-12 years: 10-60 mg/d PO divided tid/qid
Start: 2.5-5 mg PO tid x 3d; increase by 5-15 mg/d q3d prn; 60 mg/d maximum
>12 years: 20-80 mg/d PO divided tid/qid
Start: 5 mg PO tid x 3d; increase by 5-15 mg/d q3d prn; 80 mg/d maximum

Increased risk of depression with alcohol, antipsychotics, anxiolytics, MAOIs, narcotics, and tricyclic antidepressants; insulin and oral hypoglycemics may increase blood glucose levels

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal impairment or patients with seizure disorder

Anticonvulsants

Increases GABA synthesis and release and decreases GABA degradation. Used for acquired pendular nystagmus.


Gabapentin (Neurontin)

May reduce nystagmus, improve visual acuity, and reduce oscillopsia in patients with acquired pendular nystagmus.

Adult

300-1200 mg PO in divided doses

Pediatric

Not established

Antacids may decrease absorption

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal impairment and in elderly persons; avoid abrupt withdrawal


Clonazepam (Klonopin)

Used for downbeat nystagmus. Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters.

Adult

0.5-5 mg PO tid; not to exceed 20 mg PO qd

Pediatric

<10 years or <30 kg: 0.01-0.03 mg/kg PO divided bid/tid; increase by 0.25-0.5 mg q3d; not to exceed 0.1-0.2 mg/kg/d
>10 years or >30 kg: 0.5 mg PO tid; increase by 0.5-1 mg q3d; not to exceed 20 mg/d

Carbamazepine, phenytoin, and phenobarbital decrease clonazepam levels; cimetidine, itraconazole/ketoconazole, and ritonavir increase clonazepam levels; CNS depressants increase risk of CNS depression; valproic acid increases risk of absence seizures

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with impaired respiratory function; avoid abrupt withdrawal

Neuromuscular blocker agents

Blocks neuromuscular transmission at cholinergic junctions by preventing release of acetylcholine from nerve terminals. Decreases nystagmus and improves visual acuity.


Botulinum toxin A (BOTOX®)

Treats excessive, abnormal contractions associated with blepharospasm. Binds to receptor sites on motor nerve terminals and inhibits release of acetylcholine, which, in turn, inhibits transmission of impulses in neuromuscular tissue.
Reexamine patients 7-14 d after initial dose to assess for response. Increase doses 2-fold over previous one for patients experiencing incomplete paralysis of target muscle. Do not exceed 25 U when giving it as single injection or 200 U as cumulative dose in 30-day period.

Adult

Rectus muscles: 2.5 U/muscle
Retrobulbar injection: 10-25 U in 0.1-1 cm3

Pediatric

Not established

Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects of botulinum toxin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Systemic side effects have not occurred; however, electrophysiologic studies have shown that large doses produce subclinical effects on neuromuscular transmission in distant muscles

More on Nystagmus, Acquired

Overview: Nystagmus, Acquired
Differential Diagnoses & Workup: Nystagmus, Acquired
Treatment & Medication: Nystagmus, Acquired
Follow-up: Nystagmus, Acquired
References
Further Reading
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References

  1. Rucker JC. An update on acquired nystagmus. Semin Ophthalmol. Mar-Apr 2008;23(2):91-7. [Medline].

  2. Sarvananthan N, Surendran M, Roberts E, et al. The prevalence of nystagmus: The Leicestershire nystagmus survey. Invest Ophthalmol Vis Sci. May 20 2009;[Medline].

  3. Wagner JN, Glaser M, Brandt T, Strupp M. Downbeat nystagmus: aetiology and comorbidity in 117 patients. J Neurol Neurosurg Psychiatry. Jun 2008;79(6):672-7. [Medline].

  4. Daroff RB, Troost BT. Upbeat nystagmus. JAMA. Jul 16 1973;225(3):312. [Medline].

  5. Gonzalez C, Seth RK, Ramos-Esteban JC. Change in head posture and character of nystagmus in a patient with neurological upbeat nystagmus. Binocul Vis Strabismus Q. 2007;22(3):179-84. [Medline].

  6. Spielmann AC. Large recession of the four vertical rectus muscles for acquired pendular vertical nystagmus and oscillopsia without a null zone. J AAPOS. Feb 2009;13(1):102-4. [Medline].

  7. Thurtell MJ, Weber KP, Halmagyi GM. Teaching video NeuroImage: acquired or congenital gaze-evoked nystagmus?. Neurology. Jun 3 2008;70(23):e96. [Medline].

  8. Murofushi T, Chihara Y, Ushio M, Iwasaki S. Periodic alternating nystagmus in Meniere's disease: the peripheral type?. Acta Otolaryngol. Jul 2008;128(7):824-7. [Medline].

  9. Menon GJ, Thaller VT. Therapeutic external ophthalmoplegia with bilateral retrobulbar botulinum toxin- an effective treatment for acquired nystagmus with oscillopsia. Eye. Nov 2002;16(6):804-6. [Medline].

  10. Castillo IG, Reinecke RD, Sergott RC, Wizov S. Surgical treatment of trauma-induced periodic alternating nystagmus. Ophthalmology. Jan 2004;111(1):180-3. [Medline].

  11. Kumar A, Thomas S, McLean R, et al. Treatment of acquired periodic alternating nystagmus with memantine: a case report. Clin Neuropharmacol. Mar-Apr 2009;32(2):109-10. [Medline].

  12. American Academy of Ophthalmology. Basic and Clinical Science Course. In: Neuro-ophthalmology. 5. 1999-2000:139-41.

  13. American Academy of Ophthalmology. Basic and Clinical Science Course. In: Pediatric. 69(3). 1999-2000:129-35.

  14. American Medical Association. Drug Evaluations. 1995.

  15. Arnoldi KA, Tychsen L. Prevalence of intracranial lesions in children initially diagnosed with disconjugate nystagmus (spasmus nutans). J Pediatr Ophthalmol Strabismus. Sep-Oct 1995;32(5):296-301. [Medline].

  16. Averbuch-Heller L, Tusa RJ, Fuhry L, et al. A double-blind controlled study of gabapentin and baclofen as treatment for acquired nystagmus. Ann Neurol. Jun 1997;41(6):818-25. [Medline].

  17. Baloh RW, Spooner JW. Downbeat nystagmus: a type of central vestibular nystagmus. Neurology. Mar 1981;31(3):304-10. [Medline].

  18. Breen LA. Nystagmus and related ocular oscillations. In: Neuroophthalmology: Clinical Signs and Symptoms. Vol 4. 1997:504-20.

  19. Cross SA, Smith JL, Norton EW. Periodic alternating nystagmus clearing after vitrectomy. J Clin Neuroophthalmol. Mar 1982;2(1):5-11. [Medline].

  20. Donin JF. Acquired monocular nystagmus in children. Can J Ophthalmol. Jul 1967;2(3):212-5. [Medline].

  21. Glaser JS. Neuro-Ophthalmology. 1990.

  22. Leigh RJ, Robinson DA, Zee DS. A hypothetical explanation for periodic alternating nystagmus: instability in the optokinetic-vestibular system. Ann N Y Acad Sci. 1981;374:619-35. [Medline].

  23. Martin JH. Neuroanatomy Atlas. 2nd ed. McGraw-Hill Co; 1996:155-61.

  24. May EF, Truxal AR. Loss of vision alone may result in seesaw nystagmus. J Neuroophthalmol. Jun 1997;17(2):84-5. [Medline].

  25. Neely DE, Sprunger DT. Nystagmus. Curr Opin Ophthalmol. Oct 1999;10(5):320-6. [Medline].

  26. Nolte J. The Human Brain. 1993:218-23.

  27. Norton EW, Cogan DG. Spasmus nutans; a clinical study of twenty cases followed two years or more since onset. AMA Arch Ophthalmol. Sep 1954;52(3):442-6. [Medline].

  28. Pratt-Johnson JA, Tillson G. Management of Strabismus and Amblyopia: A Practical Guide. 1994.

  29. Ruben ST, Lee JP, O'Neil D, Dunlop I, Elston JS. The use of botulinum toxin for treatment of acquired nystagmus and oscillopsia. Ophthalmology. Apr 1994;101(4):783-7. [Medline].

  30. Sharpe JA, Lo AW, Rabinovitch HE. Control of the saccadic and smooth pursuit systems after cerebral hemidecortication. Brain. Jun 1979;102(2):387-403. [Medline].

  31. Stahl JS, Averbuch-Heller L, Leigh RJ. Acquired nystagmus. Arch Ophthalmol. Apr 2000;118(4):544-9. [Medline].

  32. Troost BT. Nystagmus and Related Ocular Oscillations. Available at: http://www.wfubmc.edu. 1998;[Full Text].

  33. Tusa RJ. Nystagmus: diagnostic and therapeutic strategies. Semin Ophthalmol. Jun 1999;14(2):65-73. [Medline].

  34. Tychsen L. Pediatric Ocular Motility Disorders of Neuro-ophthalmic Significance. Vol. 4. 1991:615-43.

  35. Van Stavern GP, Biousse V, Newman NJ, Leingang JC. Downbeat nystagmus from heat stroke. J Neurol Neurosurg Psychiatry. Sep 2000;69(3):403-4. [Medline]. [Full Text].

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Keywords

acquired nystagmus, downbeat nystagmus, upbeat nystagmus, periodic alternating nystagmus, horizontal nystagmus, vertical nystagmus, optokinetic nystagmus, rotary nystagmus, vestibular nystagmus, oscillopsia, congenital nystagmus, spasmus nutans

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Contributor Information and Disclosures

Author

Christopher M Bardorf, MD, MS, Ophthalmology, Children's Eye Physicians, Denver, CO
Christopher M Bardorf, MD, MS is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Gregory P Van Stavern, MD, FACP, Assistant Professor, Departments of Ophthalmology and Neurology, Wayne State University
Gregory P Van Stavern, MD, FACP is a member of the following medical societies: American Academy of Neurology and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

Enrique Garcia-Valenzuela, MD, PhD, Clinical Assistant Professor, Department of Ophthalmology, University of Illinois Eye and Ear Infirmary; Consulting Staff, Vitreo-Retinal Surgery, Midwest Retina Consultants, SC, Parkside Center
Enrique Garcia-Valenzuela, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Retina Society, and Society for Neuroscience
Disclosure: Nothing to disclose.

Medical Editor

Michael J Bartiss, OD, MD, Medical Director, Ophthalmology, Family Eye Care of the Carolinas
Michael J Bartiss, OD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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