eMedicine Specialties > Ophthalmology > Extraocular Muscles
Nystagmus, Acquired: Treatment & Medication
Updated: Aug 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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
Documented hypersensitivity
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
Documented hypersensitivity
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
Documented hypersensitivity
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
Documented hypersensitivity
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
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Further Reading
Related eMedicine topics
Nystagmus, Congenital
Electronystagmography
Dizziness, Vertigo, and Imbalance
Pelizaeus-Merzbacher Disease
Multiple Sclerosis
Clinical guidelines
EFNS task force - therapy of nystagmus and oscillopsia.
Pediatric eye evaluations: I. Screening. II. Comprehensive ophthalmic evaluation.
Eye.
Clinical trials
Visual Impairment, Oscillopsia and Multiple Sclerosis
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
Treatment & Medication: Nystagmus, Acquired