Ocular flutter associated with a localized lesion in the paramedian pontine reticular formation

Ocular flutter is a rare horizontal eye movement disorder characterized by rapid saccadic oscillations. It has been hypothesized that it is caused by loss of "pause" neuronal inhibition of "burst" neuron function in the paramedian pontine reticular formation (PPRF); however, there have been no imaging studies confirming such anatomical localization. We report the case of a woman with an acute attack of multiple sclerosis associated both with ocular flutter and a circumscribed pontine lesion, mainly involving the PPRF on magnetic resonance imaging. As she recovered from the attack, both the midline pontine lesion and the ocular flutter dramatically improved. This case is the first clear evidence that at least some cases of ocular flutter are due to lesions involving the PPRF.

Smooth pursuit eye tracking over a structured background in first-episode schizophrenic patients

Whilst most laboratory smooth pursuit tasks are performed in the dark, in everyday life pursuit commonly occurs over a structured background. This background provides a powerful stimulus to the optokinetic reflex (OKR), inducing a background "drag" on pursuit eye movements. An inability to inhibit the influence of the OKR may be a contributing factor to the dysfunctional pursuit performance observed in many schizophrenic patients. Smooth pursuit performance was measured in 23 first-episode schizophrenic patients and 23 healthy controls matched for age and estimated IQ, both in the dark and over a structured background (a random checkerboard of black and white squares). Velocity gain was measured, as well as the number and size of corrective saccades (catch-up saccades) and intrusive saccades (anticipatory saccades and square wave jerks). Overall, schizophrenic patients had lower velocity gain and made more catch-up saccades than controls. The effect of the background was to lower velocity gain and increase the number of catch-up saccades to the same extent in schizophrenic patients and controls. There were no significant interactions between group and background effect. These results suggest that, although their overall level of performance was worse, the schizophrenic patients were as able as controls to inhibit the effect of the OKR. Since lesion studies show that inhibition of the OKR requires intact inferior parietal regions in man (Lawden et al., 1995), one hypothesis is that the parietal component of smooth pursuit may be intact in schizophrenia.

Impaired spatial working memory across saccades contributes to abnormal search in parietal neglect

Visual neglect of left space following right parietal damage in humans involves a lateral bias in attention, apparent in many search tasks. We hypothesized that parietal neglect may also involve a failure to remember which locations have already been examined during visual search: an impairment in retaining searched locations across saccades. Using a new paradigm, we monitored gaze during search, while simultaneously probing whether observers judged they had found a new target, or judged instead that they were re-fixating a previously examined target. A patient with left neglect following focal right parietal infarction repeatedly re-fixated right locations. Critically, he often failed to remember that these locations had already been searched, treating old targets as new discoveries at an abnormal rate. In comparison, healthy age-matched control subjects rarely re-fixated targets, and mistook old targets as new targets even more rarely. The frequency of such mistakes in the parietal patient, for different conditions, correlated with the severity of his neglect. Control experiments indicated no perceptual localization deficit in non-search tasks. These results suggest a deficit in retaining searched locations across saccades in parietal neglect, in addition to the lateral spatial bias. Moreover, the former deficit exacerbates the latter, such that patients do not realize that the rightward locations favoured by their bias have already been examined during previous fixations and, for this reason, they saccade back to them repeatedly. The combination of the two deficits (a lateral bias plus a deficit in retaining locations already searched) may thus explain the pathological pattern of search that characterizes parietal neglect: why stimuli on the right are re-examined recursively, as if being searched for the first time, and hence why stimuli on the left continue to be ignored even with unlimited viewing time. These proposals accord with recent electrophysiological and functional imaging data, demonstrating posterior parietal involvement in the retention of target locations across saccades.

The preparation and execution of saccadic eye and goal-directed hand movements in patients with Parkinson's disease

The oculomotor and manual motor systems were studied in a two-segment movement task in a group of patients with Parkinson's disease and in age matched normal controls. In order to avoid reflexive motor movements the selection of the correct motor sequence was derived from the interpretation of symbolic (coloured) cues. The latencies and dynamics of eye and hand (pointing) movements performed during the first (fixed) movement segment were measured and the planning and execution processes were manipulated by varying the complexity of the second movement segment relative to the first (with regard to direction and amplitude). The results showed that the eye and hand movements made by patients with Parkinson's disease were not impaired in the initiation of the first movement segment. Interestingly, both Parkinson's patients and controls showed increased eye and hand reaction time latencies for the first movement when the second movement was in the direction opposite to the first. This indicates that the complexity of the second movement influences the execution of the first movement, and importantly that complexity affects motor initiation and execution processes in both normal subjects and in patients with Parkinson's disease. The execution of hand movements was found to be impaired in patients with Parkinson's disease as indicated by a reduced peak velocity of manual pointing responses when compared to age matched controls. By contrast, no differences were found in the dynamics of saccadic eye movements. This dissociation is consistent with the notion that the skeletomotor loop passes through the functionally corresponding portions of the basal ganglia independently of the oculomotor loop. Together, these results demonstrate that Parkinson's patients are able to generate multiple non-reflexive eye and hand movements and that the observed (manual) motor deficits are specific to the processes of motor execution.

The functional anatomy of single-word reading in patients with hemianopic and pure alexia

We investigated single-word reading in normal subjects and patients with alexia following a left occipital infarct, using PET. The most posterior brain region to show a lateralized response was at the left occipitotemporal junction, in the inferior temporal gyrus. This region was activated when normal subjects, patients with hemianopic alexia and patients with an incomplete right homonymous hemianopia, but no reading deficit, viewed single words presented at increasing rates. This same area was damaged in a patient with pure alexia ("alexia without agraphia") and no hemianopia, who read words slowly using a letter-by-letter strategy. Although the exact level of the functional deficit is controversial, pure alexia is the result of an inability to map a percept of all the letters in a familiar letter string on to the mental representation of the whole word form. However, the commonest deficit associated with "pure" alexia is a right homonymous field defect; an impairment that may, by itself, interfere with single-word reading because of inability to see the letters towards the end of a word. The relative contributions of pure and hemianopic alexia in individual patients needs to be assessed, as the latter has been shown to respond well to specific rehabilitation programmes.

Selectively impaired reaction time in Parkinson's disease: persistent absence of simple reaction advantage in a patient with frontal complications

The search for specific patterns of impaired reaction time in Parkinson's disease has yielded conflicting results. We propose subtypes that exhibit different patterns of impairment and report the case of a patient, Jobe, whose simple and binary choice reaction times were tested repeatedly in a variety of stimulus-response paradigms over a period of 4 years. Jobe consistently failed to exhibit the normal simple reaction advantage even though his choice reaction times fell well within the normal range. While his general intellectual status was above average, he had great difficulty with some neuropsychological tests. He was seldom able to acquire a new category in the Wisconsin Card Sort Test and also had difficulty with the Tower of London Test. We ascribe Jobe's selective impairment of simple reactions to an inability to engage in the off-line preparatory processing that confers an advantage on simple reactions.

Saccadic hypometria in drug-naive and drug-treated schizophrenic patients: a working memory deficit?

In certain conditions patients with schizophrenia make markedly smaller (hypometric) saccades than controls. This hypometria has been thought to reflect dopaminergic blockade as a result of antipsychotic medication. We tested this hypothesis by comparing the performance of an antipsychotic-naïve group and an antipsychotic-treated group of first-episode schizophrenic patients on a predictive saccade paradigm. We explored the possibility that hypometria reflects a spatial working memory deficit by correlating performance on neuropsychological tests of mnemonic function with saccadic accuracy. Both the drug-naïve and treated schizophrenic patients made hypometric saccades when compared with a group of matched controls. Primary saccade amplitude also correlated significantly with performance on some of the neuropsychological tests. These results are discussed in terms of the roles of cortical dopamine and working memory deficits in schizophrenic patients.

Scanning the visual world: a study of patients with homonymous hemianopia

OBJECTIVES

This study examined the scanpaths of patients with homonymous hemianopia while viewing naturalistic pictures in their original and also spatially filtered forms. Features of their scanpaths with respect to various saccade and fixation parameters were examined to determine whether they develop compensatory eye movement strategies. The effects of various lesion parameters including location, size, and age on the evolution of such strategies were considered.

METHODS

Eye movements of eight patients with homonymous hemianopia (four left, four right), but lacking neglect, were recorded while they viewed 22 images of real scenes, and they were compared with the eye movements of eight age matched controls. Subjects viewed each image for 3 seconds, initially in a spatially filtered form in which much of the semantic content had been removed, and then in their unfiltered, original form.

RESULTS

Patients differed significantly from controls in various fixation and saccade parameters. For fixation parameters patients with hemianopia fixated different spatial positions from controls, made more fixations which were more widely distributed and of shorter duration than controls, and spent a greater proportion of their total fixation time in the area corresponding to their blind hemifield. They did not make significantly more refixations than controls. For saccade parameters patients made more saccades into their blind hemifield, these saccades having shorter latencies and shorter amplitudes than those made into their seeing field, and had longer scanpaths than control subjects. The amplitude of their first saccade was longer than that of controls although its direction did not correlate simply with the side of the field defect. Their mean saccade amplitude was similar to that of controls. Filtering out high spatial frequencies within images seemed to accentuate the described differences between eye movement characteristics of hemianopes and controls. Scanpath differences correlated with increasing age but not location or size of lesions causing the hemianopia.

CONCLUSION

Various features of scanpaths produced by hemianopes were different from normal subjects. These differences correlated with lesion age and may reflect the evolution of a compensatory eye movement strategy.

Current orientation induced by magnetic stimulation influences a cognitive task

The direction of the current induced by transcranial magnetic stimulation (TMS) over the motor cortex has been observed to influence the threshold and latency of evoked muscle responses. This study investigates the effect of TMS-induced current orientation (ICO) over the prefrontal cortex, on a specific cognitive task (memory-guided saccade). TMS was applied with a figure-of-eight coil, placed at one of eight different orientations over the prefrontal cortex. The most effective ICO was antero-lateral, which is a different optimal ICO from that seen over the hand area of the motor cortex. This demonstrates that ICO can alter the effect of TMS on cognitive functions and that ICO is an independent variable that should not be ignored when designing TMS studies.

The strategic control of gaze direction in the Tower-of-London task

In this paper, we describe a novel approach to the study of problem solving involving the detailed analysis of natural scanning eye movements during the "one-touch" Tower-of-London (TOL) task. We showed subjects a series of pictures depicting two arrangements of colored balls in pockets within the upper and lower halves of a computer display. The task was to plan (but not to execute) the shortest movement sequence required to rearrange the balls in one half of the display (the Workspace) to match the arrangement in the opposite half (the Goalspace) and indicate the minimum number of moves required for problem solution. We report that subjects are more likely to look towards the Goalspace in the initial period after picture presentation, but bias gaze towards the Workspace during the middle of trials. Towards the end of a trial, subjects are once again more likely to fixate the Goalspace. This pattern is found regardless of whether the subjects solve problems by rearranging the balls in the lower or upper visual fields, demonstrating that this strategy correlates with discrete phases in problem solving. A second experiment showed that efficient planners direct their gaze selectively towards the problem critical balls in the Workspace. In contrast, individuals who make errors spend more time looking at irrelevant items and are strongly influenced by the movement strategy needed to solve the preceding problem. We conclude that efficient solution of the TOL requires the capacity to generate and flexibly shift between control sets, including those underlying ocular scanning. The role of working memory and the prefrontal cerebral cortex in the task are discussed.

Distinguishing sensory and motor biases in parietal and frontal neglect

Left neglect after right-hemisphere damage may involve perceptual and/or motor impairments. Here we discuss the limitations of previous attempts to separate these components, and introduce a new method. Six neglect patients (three with right inferior parietal lesions and three with right inferior frontal lesions) moved their right hand to a target light, which appeared unpredictably on either the left or the right of central fixation. The target appeared alone or with a distractor light in the opposite hemifield. Any directional motoric bias was measured by comparing reaches from a central start position with those for the same visual displays, but starting from the left of both possible targets (thus requiring only rightward reaches) or from the right (requiring only leftward reaches). All patients were slower to initiate reaches to left than right targets from a central start, which could reflect perceptual and/or motor biases. Critically, in the parietal neglect group only, initiation speed for left targets improved when a rightward reach was required to these (from a left start) rather than a leftward reach. This suggests a deficit in programming leftward movements into left hemispace, in addition to any visual impairment, for parietal neglect. A control task confirmed that this effect of start position was due to the associated change in reach direction and not to afferent inputs from the hand as it rested at the start position. Frontal neglect patients were slow to execute reaches to left targets, regardless of movement direction. Right visual distractors slowed visual reaction times to left targets more than vice versa in frontal neglect patients, and likewise for reach execution times in parietal neglect patients, suggesting that visual distractors on the neglected side have less impact. Distractor effects were unaffected by start position in the frontal neglect group (suggesting a perceptual basis), but distractors slowed reach initiation in the parietal neglect group only from left and central starts. Taken together, these findings demonstrate a directional motor component to parietal but not frontal neglect, and suggest that in man the inferior parietal lobe plays a role not only in perception but also in the programming of selective reaches. These conclusions are related to recent single-unit data from the monkey parietal lobe.

The oculomotor distractor effect in normal and hemianopic vision

The present study investigated the inhibitory effect of visual distractors on the latency of saccades made by hemianopic and normal human subjects. The latency of saccades made by hemianopic subjects to stimuli in their intact visual field was not affected by visual distractors presented within their hemianopic field. In contrast, the latency of saccades made by normal subjects was increased significantly under distractor conditions. The latency increase was larger for temporal than nasal distractors. The results are inconsistent with previous proposals that the crossed retinotectal pathway from the nasal hemiretina to the superior colliculus may mediate a blindsight inhibitory effect when distractors appear within a hemianopic temporal visual field. Instead, the distractor effect appears to reflect the normal processes involved in saccade target selection which may be mediated by a circuit involving both cortical and subcortical structures.

Disorders of higher visual function and hemi-spatial neglect

Lesions of the extrastriate cerebral cortex result in disorders of vision, which reveal two cortical processing streams extending ventrally and dorsally from the primary visual cortex. Current theories emphasize the visual perceptual and visuomotor specialization of the ventral and dorsal streams, respectively. Recent investigations of hemi-spatial neglect suggest that the inferior parietal region may lie at the junction of the visual and motor processing pathways.

Control of voluntary and reflexive saccades

The latency of 'reflexive' saccades (made in response to peripheral visual stimuli) was compared to that of 'voluntary' saccades performed in anti-saccade and symbolically cued paradigms. Manipulation of visual events at fixation was carefully controlled across all conditions. Reflexive saccade latency was significantly faster than the latency of all forms of voluntary saccades. Importantly, the latency of saccades made after presentation of a symbolic cue at central fixation (voluntary arrow-cue condition) was greater than that made in the anti-saccade paradigm that requires suppression of a reflexive response. It is suggested that the increase in latency of saccades made in the voluntary arrow-cue condition may reflect differences in programming a 'When' trigger signal for saccades made in the absence of a peripheral stimulus.

Deficits of smooth pursuit initiation in patients with degenerative cerebellar lesions

It is well known that cerebellar dysfunction can lead to an impairment of eye velocity during sustained pursuit tracking of continuously moving visual target. We have now studied the initiation of smooth pursuit eye movements towards predictable and randomized visual step-ramp stimuli in six patients with degenerative cerebellar lesions and six age-matched healthy controls using the magnetic scleral search-coil technique. In comparison with the control subjects, the cerebellar patients showed a significant delay of pursuit onset, and their initial eye acceleration was significantly decreased. These cerebellar deficits of pursuit initiation were similarly found in response to both randomized and predictable step-ramps, suggesting that predictive input does not compensate for cerebellar deficits in the initiation period of smooth pursuit. When we compared initial saccades during smooth tracking of foveofugal and foveopetal step-ramps, the absolute position error of these saccades did not significantly differ between patients and controls. In fact, none of the patients showed any bias of the saccadic position error that was related to the direction or velocity of the ongoing target motion. This work presents further evidence that the effect of cerebellar degeneration is not limited to the impaired velocity gain of steady-state smooth pursuit. Instead, it prolongs the processing time required to initiate smooth pursuit and impairs the initial eye acceleration. These two deficits were not associated with an abnormal assessment of target velocity and they were not modified by predictive control mechanisms, suggesting that cerebellar deficits of smooth initiation are not primarily caused by abnormal information on target motion being relayed to the cerebellum.

Saccades and smooth pursuit in myotonic dystrophy

Reflexive saccades, remembered saccades, antisaccades, fixation and smooth pursuit were recorded in seven subjects with myotonic dystrophy (MD) and seven age-matched controls using the magnetic scleral search coil technique. Neuropsychological performance was assessed using the Wisconsin Card Sort Test and measures of verbal fluency. Subjects with MD showed significantly elevated error rates in the antisaccade and remembered saccade paradigms, consistent with prefrontal dysfunction, and these two measures of distractibility were significantly correlated with each other. Saccadic latencies, square wave jerk frequency, and smooth pursuit peak velocity gain showed no significant difference between the two groups, although the peak velocity of all classes of saccades was significantly reduced in patients with MD. These results extend the findings of previous studies of oculomotor function in MD, and provide novel evidence for a central contribution to abnormalities of eye movements in this condition.

Eye movements and spatial working memory in Parkinson's disease

Mechanisms of spatial working memory and eye movement control were investigated in eight mild to moderate Parkinson's disease patients (PDs). Subjects were presented with a sequence of four targets which had to be memorized and then recalled by moving their eyes to fixate the four locations in the correct order. Two variations on this procedure were used in which either a different sequence of lights was presented on each trial, or an identical sequence of lights was repeated on each trial. In both conditions subjects made memory-guided eye movements in the dark, without any visual cues to eye movement accuracy or the locations of the previously illuminated lights. Analysis of the amplitude of the primary eye movement and final eye position for each step in the sequence showed that PDs made several discrete saccadic eye movements of reduced amplitude before reaching the final eye position (multi-stepping). When a novel target sequence had to be memorized on each trial, the final eye position reached by PDs for each location was also found to undershoot relative to controls. In contrast, when an identical sequence of targets was repeated on each trial, PDs' final eye position was found to be normal, although primary movement amplitudes were still reduced. PDs showed no multi-stepping and normal final eye position gain under conditions for which the target lights in the sequence were illuminated during movement execution. PDs also made an increased proportion of overt errors in target sequence recall. Parallel neuropsychological testing in PDs and controls revealed that error rates in the sequential memory-guided saccade task were significantly correlated with performance in a task thought to be sensitive to spatial working memory dysfunction. The findings suggest that short-term spatial memory representations are disrupted in the early stages of PD.