Acquired Nystagmus Treatment & Management

Updated: Jun 22, 2021
  • Author: Huy D Nguyen, MD, MBA; Chief Editor: Edsel B Ing, MD, MPH, FRCSC, PhD, MA  more...
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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. Contact lenses may also reduce nystagmus by reducing abnormal eye movements and enhancing sensory feedback. This usually only applies to congenital nystagmus. [16]  Topical brinzolamide was also found to improve acuity and the characteristics of central nervous waveforms in the primary position null zone in congenital nystagmus. [18]

Prism therapy may be useful for inducing convergence or shifting the null point to the primary position (ie, straight ahead gaze). Base-out prisms (eg, 7 diopters) with a -1.00 myopic correction may be used for convergence damping in infantile nystagmus. Base-out prisms (to induce convergence) have also been described to treat downbeat nystagmus with a pseudocycloid waveform. [37]  Prisms may be useful prior to considering surgery for a head turn. Placing prisms over both eyes with the apices directed towards the preferred gaze position may help shift the line of sight to the primary, straight ahead gaze, thus eliminating the need to adopt abnormal head positions. 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. [37]

 

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Surgical Care

Surgical treatment may include the following:

  • Removing the inciting etiology if possible (ex. 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. Botulinum toxin may also be used to eliminate compensatory head tilting and tremors.
    • The toxin may be injected into the rectus muscles (2.5 U per muscle) or may be given as a retrobulbar injection [17]  (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 (ex. saccades, smooth pursuit).
    • Complications of toxin injection include ptosis, diplopia, increase of nystagmus in the noninjected eye, and, rarely, globe rupture.
  • Extraocular muscle surgery (Anderson-Kestenbaum procedure) for correction of nystagmus is based on surgically shifting the null zone into primary position (straight ahead position). Again, null zones are more characteristic of congenital nystagmus; thus, they may not be applicable to most forms of acquired nystagmus. Tetonomy, a controversial procedure in which all four recti muscles are detached and re-attached at their original insertion sites, has been reported to improve foveation and vision. Tetonomy combined with strabismus surgery has been shown to improve visual function in patients with ocular misalignment and congenital nystagmus. [18]  Retroequatorial rectus muscle recessions have been shown to be effective in treating acquired nystagmus without a null point, as has extraocular muscle tenotomies with reattachment. [17, 38]
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Consultations

Consider neurologic or neuro-ophthalmic consultation.

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.

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Long-Term Monitoring

Regular office visits are useful to monitor nystagmus.

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