surgical mgmt.of nystagmus
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Surgical Management ofNystagmus
Abdulaziz Awad, MDSenior Academic Consultant
Pediatric Ophthalmology Division
King Khaled Eye Specialist HospitalRiyadh, Saudi Arabia
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Nystagmus
It is a term used to describe
oscillatory ocular movements that are"to a certain extent rhythmic".
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Types of Nystagmus
Nystagmus
Pendular Jerk
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Pendular Nystagmus
Ocular oscillations in which the velocity
in both directions is approximately
equal.
Cases of pendular nystagmus are
almost always horizontal.
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Jerk Nystagmus
Rhythmic oscillations in which the
movement in one direction is recognizably
faster than the movement in the other
direction.
– The slow movement is the pathologic
movement.
– The fast movement is corrective.
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Jerk Nystagmus
Is named according to the direction of the
fast phase or corrective movement.
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Null Point
Both pendular and jerk nystagmus may
have a gaze position in which the intensity
(amplitude and frequency) of the ocular
oscillation is at a minimum.
Position of relative stability.
Patient will adopt a head or eye turn tomaintain the eye in null position
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Head Tilt
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Pendular
Left Beating
Right Beating
Rotatory
Horizontal Rotatory
Up Beating
Down Beating
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9 Positions of Gaze
REye
LEye
Null Point
10°
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Medical History
Time of onset.
Family history.
Drug use / abuse: – Tranquilizers.
– Anti-epileptics.
– Antibiotics. – Alcohol.
Head trauma.
Neurosurgical
intervention. Seizures.
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Ophthalmic Evaluation
VA
Refraction
EOM Pupils
Slit lamp examination
Dilated fundus exam
Visual field
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Electrophysiology
ERG should be considered to exclude
retinal dystrophies e.g. congenital stationery
night blindness .
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Ocular Nystagmus
History
Nystagmus present in
first 3 months of life
Acquired Nystagmus
Congenital
Nystagmus
Latent
Nystagmus
Manifest
Latent
Nystagmus
Examination
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Ocular Nystagmus
History
Nystagmus present infirst 3 months of life
Acquired Nystagmus
CongenitalNystagmus
Latent
Nystagmus
Manifest
Latent
Nystagmus
Examination
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Congenital Nystagmus
With
Sensory Defect
Without
Sensory Defect
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Congenital Nystagmus
With
Sensory Defect
Without
Sensory Defect
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Congenital Nystagmus
With Sensory Defect
Poor visual acuity.
Associated with:
– Optic nerve hypoplasia. – Leber's congenital
amaurosis.
– Oculocutaneous albinism.
– Cone dystrophies.
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Congenital Nystagmus
With Sensory Defect
Fine jerk nystagmus
Photophobia
Myopia more than – 5 diopter Look for Cone Rode dystrophy
ERG
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Congenital Nystagmus
With
Sensory Defect
Without
Sensory Defect
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Congenital Nystagmus
Without Sensory Defect
Better reading vision than distance
vision.
Theories: – Failure of the slow eye movement control
system.
– Defect in the subcortical optokinetic
system.
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Congenital Nystagmus
Classic Presentation
The nystagmus is bilateral.
Grossly symmetric in amplitude and
frequency. Horizontal in all directions.
No oscillopsia
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Congenital Nystagmus
Classic Presentation cont.
Rotary component may be in lateral gaze.
There is relative null point.
Nystagmus disappears during sleep.
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Congenital Nystagmus
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Ocular Nystagmus
History
Nystagmus present infirst 3 months of life
Acquired Nystagmus
Congenital
Nystagmus
LatentNystagmus
Manifest
Latent
Nystagmus
Examination
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Latent Nystagmus
Congenital jerk nystagmus induced by
monocular occlusion.
– Is not recognized until later in life.
– Poor acuity if each eye is tested individually.
The fast phase away
from the occluded eye
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Latent Nystagmus
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Manifest Latent Nystagmus
Jerk nystagmus occurs in patients with
congenital strabizmus.
– This nystagmus can be converted from a
manifest to a latent nystagmus if the eyes are
surgically aligned.
Jerk nystagmus in the
direction of the fixing eye.
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Although the term „ Acquired Nystagmus‟
has been applied to spasmus nutans, it
should be remembered that congenital
nystagmus is also „acquired‟ early in
infancy.
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Examination
Monocular or Asymmetric
Binocular Nystagmus
Binocular
Symmetric Nystagmus
Acquired Nystagmus
Acquired Nystagmus
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Examination
Monocular or Asymmetric
Binocular Nystagmus
Binocular
Symmetric Nystagmus
Acquired Nystagmus
Acquired Nystagmus
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Examination
Primary Position Eccentric Gaze
Monocular or Binocular
Asymmetric Nystagmus
Spasmus nutans.
Monocular visual deprivation.
Superior oblique myokymia. Motor nystagmus of MS.
Internuclear ophthalmoplegia.
Pseudo-internuclear ophthalmoplegia.
Cranial nerve paresis. Restrictive syndromes.
Superior oblique myokymia.
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Examination
Primary Position Eccentric Gaze
Monocular or Binocular
Asymmetric Nystagmus
Spasmus nutans. Monocular visual deprivation.
Superior oblique myokymia. Motor nystagmus of MS.
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Spasmus Nutans
Triad of nystagmus, head tilt, and head
nodding.
4 - 14 months.
Nystagmus is small amplitude, may be
horizontal, vertical or rotary.
Disappears at 5 years of age.
If it starts after 14 months of age; MRI
to exclude chiasmal or ventricular
tumors.
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Spasmus Nutans
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Management
Complete ophthalmic examination, including
electrophysiology studies.
MRI is recommended in cases associated
with neurological signs:
– Seizures.
– Hypotonia.
– Developmental delay.
– Systemic anomalies.
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Conclusions
Congenital nystagmus is the most
common form of nystagmus in infants
and children.
A majority of individuals with congenital
nystagmus have a primary disturbance of
the anterior visual pathways.
In Congenital Motor Nystagmus, no
clinical or electrophysiological evidence
of sensory visual deficit can be found.
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Management Modalities
MedicalVisual Training (strabismus, binocular dysfunction)
Acupuncture
BiofeedbackVibratory Stimulation
Prisms, Telescopes, Contact Lenses
Botox
Eye Muscle Surgery
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Medical Treatments
Spectacles
Contact Lenses
Low Vision Aids
Penalization
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Medical Treatments Photophobia
Nystagmus
• Sedatives, hypnotics, Nueroleptics, Anti-seizure drugs
• Acupuncture, Biofeedback, Vibratory Stimulation
Strabismus and binocular dysfunction
• Orthoptics
• Spectacles
• Penalization
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“Nystagmus” Surgery
Effect a Positive Change on the Oscillation
Improves Waveform
Increase Foveation
Broaden Null Position Improve Periodicity
Treat Anomalous Head Positions
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Indications and SurgicalTreatments of Nystagmus
Anomalous head/face posture
“Anderson-Kestenbaum” resection-recession
OU (horizontal gaze null)
Vertical rectus resection-recession/transposition(vertical gaze null)
Bilateral oblique muscle recession/transportation
(vertical gaze null)Horizontal transposition of vertical recti (torsional
gaze null)
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Indications and SurgicalTreatments of Nystagmus cont.
Strabismus
Recession/resection surgery as indicated
(promotion of fusion)
Oscillopsia
Retroequatorial rectus recession
Botox injection
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Indications and SurgicalTreatments of Nystagmus cont.
INS and “convergence damping”
Bimedial rectus recession
Decreased visionRetroequatorial rectus recession
Horizontal rectus tenotomy
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Increased Foveation Increased Foveation (amount of time during a
beat of INS during which the eye is moving at <4deg/sec and within a few degrees of the target –
when the eye/brain “sees”)
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Improved Waveforms
Improved Waveforms (Pure Jerk and Pendular to
Jerk/Pendular with foveation)
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Increased Breadth of The Null Zone
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Gaze Dependent Visual Acuity
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C l i
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Conclusions
Ask for:
Accurate Evaluation Afferent System
Efferent System
Accurate DiagnosisSensory system DeficitsNystagmus Type
Strabismus
Head Posturing
Medical Treatment Options Surgical Treatment Options Treatment versus “CURE”
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