Common Disturbances of Ocular Motility
Clinical Finding | Syndrome | Common Causes |
|---|---|---|
Pareses | ||
Paresis of horizontal gaze in one direction | Lesion in the ipsilateral pontine horizontal gaze center or in the contralateral frontal cortex | |
Paresis of horizontal gaze in both directions | Complete (bilateral) horizontal gaze palsy | Large bilateral pontine lesion affecting both horizontal gaze centers |
Bilateral paresis of all horizontal eye movements except for abduction of the eye contralateral to the lesion; convergence unaffected | Lesion in the medial longitudinal fasciculus and ipsilateral pontine horizontal gaze center | |
Unilateral or bilateral paresis of eye adduction in horizontal lateral gaze but not in convergence | Lesion in the medial longitudinal fasciculus | |
Bilateral paresis of upward eye movement with dilated pupils, loss of the pupillary light response despite preservation of pupillary accommodation and constriction with convergence, downward gaze preference, and downbeating nystagmus | Parinaud syndrome (a type of conjugate vertical gaze palsy) | Pineal tumor Dorsal midbrain infarct |
Bilateral paresis of downward eye movements | Progressive supranuclear palsy | |
Unilateral eye deviation (resting position is down and out); unilateral paresis of eye adduction, elevation, and depression; ptosis; and often a dilated pupil | Aneurysms Oculomotor nerve or midbrain microvascular disease (diabetes and hypertension) Trauma | |
Unilateral paresis of downward and inward (nasal) eye movement, which may be subtle, causing symptoms (difficulty looking down and inward) Head tilt sign (patient tilts the head to the side opposite the affected eye) | Idiopathic Head trauma Ischemia Congenital | |
Unilateral paresis of eye abduction | Idiopathic Increased intracranial pressure Microvascular disease secondary to diabetes or hypertension Trauma | |
Skew deviation (vertical misalignment of the eyes) | Partial and unequal involvement of 3rd cranial nerve nuclei, vertical gaze center, or median longitudinal fasciculus | Brain stem lesion anywhere from midbrain to medulla |
Weakness or restriction of all extraocular muscles | External ophthalmoplegia | Dysfunction of eye muscles or of neuromuscular junction Usually caused by the following:
|
Involuntary or abnormal movements | ||
Rhythmic involuntary movements, usually bilateral | Many causes:
| |
Fast downward jerk and slow upward return to midposition | Ocular bobbing | Extensive pontine destruction or dysfunction |
Gaze overshoot followed by several oscillations | Ocular dysmetria | Cerebellar pathway disorders |
Burst of rapid horizontal oscillations about a point of fixation | Ocular flutter | Many causes:
|
Rapid, conjugate, multidirectional, chaotic movements, often with widespread myoclonus | Opsoclonus | Many causes (same as for ocular flutter, above) |