Localizing forms of nystagmus: Symptoms, diagnosis, and treatment

Nystagmus in children with primary brain tumours in Denmark between 2007 and 2017

BACKGROUND

The aim of the study was to evaluate the prevalence, clinical characteristics, and diagnostic importance of nystagmus in children with brain tumours.

METHODS

A nation-wide retrospective review of all children diagnosed with a brain tumour between January the 1st, 2007 and December 31st, 2017, in Denmark. Data is based on information from the Danish Childhood Cancer Registry, hospital records from paediatric- and ophthalmological departments, and records from private ophthalmologists.

RESULTS

Nystagmus was observed in 13.7% (60/437) of children with a brain tumour. In 50/60 children (83.3%) nystagmus was an incidental finding at the clinical examination and only in 10/60 children (16,7%) were nystagmus noticed by patient/caregivers prior to the clinical examination. In 38/60 children nystagmus was observed before the brain tumour diagnosis, most often (16/38, 42%) the same day as the diagnosis was made. In 22/60 children nystagmus was found after the brain tumour diagnosis (prior to any treatment) with a median of four days (range 0-47) after the brain tumour diagnosis. Nystagmus was most commonly binocular (56/60, 93.3%) and gaze-evoked (43/60, 71.7%). The median number of additional symptoms and/or clinical findings was five (range 0-11).

CONCLUSION

Nystagmus is frequent in children with brain tumours and is typically accompanied by other symptoms and clinical signs. However, nystagmus is often first recognized by the ophthalmologist late in the time course. Therefore, raising awareness of the importance of looking for nystagmus in children with unspecific neurological symptoms might contribute to increased suspicion of brain tumour and thereby faster diagnosis.

The presenting visual symptoms of optic chiasmal disease

Recognising optic chiasmal disease early is important in order to avoid irreversible visual loss and the potential risk of mortality for patients. Yet, there is frequently a delay in the initial diagnosis. Whilst the signs of optic chiasmal disease, particularly the perimetric findings, are well documented in the recent literature, the symptoms have been less well reported. Whilst some patients with optic chiasmal disease will be asymptomatic, many will complain of visual symptoms including symptomatic field defects, problems with central vision, difficulty with near tasks, binocular visual disturbances, colour vision disturbances, photophobia, phosphenes, glare, and rarely, oscillopsia and visual hallucinations. Others may have headache or the severe and sudden visual symptoms associated with pituitary apoplexy. The visual symptoms may be vague or non-specific, even when there are significant bitemporal visual field defects. We aim in this review to describe the presenting visual symptoms of optic chiasmal disease, and to illustrate these with selected qualitative descriptions from the literature. Our hope is that this will aid clinicians in eliciting a careful history of the sometimes subtle symptoms that may be present.

Binocular, Accommodative and Oculomotor Alterations In Multiple Sclerosis: A Review

Multiple sclerosis (MS) is an acquired demyelinating and inflammatory neurodegenerative disease affecting the central nervous system (CNS). Clinical and subclinical ocular disturbances occur in almost all patients with MS. The objective of this narrative review was to collect and summarize the available scientific information on oculomotor, accommodative and binocular alterations that have been reported in MS. A systematic search strategy with the following descriptors was carried out: multiple sclerosis, ocular motility disorders, internuclear ophthalmoplegia, nystagmus, vergences, fixation, pupil reflex, accommodation and stereopsis. According to the search, some oculomotor alterations were found to be commonly reported in MS, such as alterations in saccades and nystagmus. In contrast, accommodative, vergence and stereopsis alterations have not been comprehensively studied despite their relevance, with only minimal evidence showing a potential negative impact of the disease on these aspects. In conclusion, oculomotor impairment is a common component of disability in MS patients and should be considered when managing this type of patients. More research is still needed to know the real impact of this disease on binocular vision and accommodation.

Stable cell lines of human SH-SY5Y uniformly expressing wild-type or mutant-type FERM domain containing 7 gene

It has been reported that FERM domain containing 7 (FRMD7) may cause X-linked idiopathic congenital nystagmus (ICN). A total of >40 mutations of the FRMD7 gene have been identified, however their pathogenic role remains unclear. In the present study, enhanced green fluorescent protein-tagged wild-type (WT) and mutant (MT) FRMD7 (c. C781>G) were expressed in stably expressing human neuroblastoma SH-SY5Y cells following viral transfection and antibiotic selection. Uniform expression of the FRMD7 fusion proteins was confirmed via fluorescence microscopy and western blotting. The expression profiles of neuron-specific proteins and Rho guanine triphosphatases (GTPases) differed significantly between the wild-type and mutant cell lines. Levels of Mtap2, NF-M, nestin, GAP43 and Rac1 mRNA were significantly increased in MT-FRMD7 cells compared with controls (P<0.01). However, the expression of Rac1 protein did not differ significantly among the two cell lines. Taken together, the results of the current study suggest that MT-FRMD7 influences the expression of neuron-specific genes and Rho GTPases, which may be involved in the pathogenesis of ICN. The FRMD7 stable expression cell line may facilitate future studies investigating the role of this protein in neuronal development.

The role of MR imaging in investigating isolated pediatric nystagmus

BACKGROUND

The use of MRI in isolated pediatric nystagmus remains a gray area in clinical management. Many clinicians prefer to order an MRI to rule out intracranial pathology despite the lack of clinically significant findings in most cases.

OBJECTIVE

To assess the yield of MR imaging in isolated pediatric nystagmus and define a management algorithm to minimize avoidable MRI referrals and streamline MRI protocols.

MATERIALS AND METHODS

We reviewed the charts of 148 children who underwent neuro MRI for isolated nystagmus between January 2008 and September 2014. We noted nystagmus onset and clinical characteristics and compared them with the MRI features and visual electrophysiology results.

RESULTS

We included 85 boys and 63 girls (total 148, average age at MRI 4.24 ± 4.19 years). Twenty-three (15.5%) children had abnormal intracranial findings on MRI including abnormal signal lesions (4.1%; n=6), Chiari I malformations (3.4%; n=5) and optic pathway glioma (2.0%; n=3). The time of onset of nystagmus was not associated with an abnormal MRI (P=0.2). Seventy children underwent visual electrophysiology testing but this test could not predict abnormality at MRI, either (P=0.12).

CONCLUSION

Among children with isolated nystagmus, 15.5% had abnormalities on neuroimaging. Neither clinical characteristics of nystagmus nor the visual electrophysiology results allowed prediction of intracranial pathology. We were unable to formulate a management algorithm for the optimal sequence of investigations (MRI preceding visual electrophysiology or vice versa), but we discuss the use of gadolinium contrast agent and orbital sequences in isolated pediatric nystagmus.

Quantification of visual function assessment using remote eye tracking in children: validity and applicability

PURPOSE

Measurements of visual and oculomotor functions are essential for providing tailored support to visually impaired children. In young or intellectually disabled children these measurements can be difficult or even impossible to perform. Recordings of orienting gaze in response to specific visual information, made with eye tracking, may offer a solution. The aim of this study was to observe and quantify eye tracking (ET)-based gaze responses to provide information about visual and oculomotor functioning, and to compare this information with standard visual function assessments (VFA).

METHODS

One hundred and twenty-six visually impaired children from 1-14 years underwent a VFA. Next they underwent a remote ET test. Four aspects of oculomotor control (nystagmus, fixation, saccades, pursuit) and three visual functions (visual field, contrast, colour) were selected to compare both methods. Performance was assessed (1) during VFA using standard behavioural observation and test scores and (2) after ET by observing and scoring the eye movement recordings. Validity, in terms of agreement between results, was measured by correlation analyses. From the orienting gaze responses, quantitative parameters (gain, fixation duration and directional saccades) were calculated to characterize visual performance.

RESULTS

Good agreement between the two test methods was found for observational assessment of oculomotor control and visual functions (correlations ranging from rs  = 0.39 to rs  = 0.69). The quantitative parameters of visual performance showed distinct results between children with and without specific functional impairments, both in children aged 1-6 and 7-14 years.

CONCLUSION

Eye tracking-based gaze recordings are a promising tool to assess oculomotor and visual performance in a communication-free manner. Calculating quantitative parameters from specific gaze responses could assist in the characterization of functional visual performance in children, independent of age. Gaze responses are a useful addition to standard VFA in clinical practice.

Validity of a screening question for head tremor: an analysis of four essential tremor case samples

BACKGROUND

The goal of this study was to assess the validity of a screening question for head tremor in essential tremor (ET). There are no published data on this topic, and the knowledge will guide future epidemiological investigations of this disorder.

METHODS

These analyses utilized four distinct patient samples: a population-based study in northern Manhattan, a study of the environmental epidemiology of ET, a genetics study, and a brain repository. Sensitivity was the proportion of ET cases with head tremor on examination who self-reported head tremor.

RESULTS

The sensitivity of the screening question for head tremor was lowest in the population-based study (31.6%), and higher as well as somewhat similar across the remaining studies (46.7 to 62.2%). Higher sensitivity was associated with tremor of longer duration, presence of voice tremor on examination, female gender, and lower education. The use of the screening question would have increased case ascertainment during the screening phase of these four studies by 1.9, 4.1, 10.2, and 20.3%.

CONCLUSIONS

A screening question for head tremor had low-to-moderate sensitivity in ET. The use of such a screening questionnaire, however, has the potential to increase case ascertainment by as much as 20% in some screening settings.

Intracranial pathology in young children with apparently isolated nystagmus

PURPOSE

To assess the incidence of intracranial pathology in young children who had brain magnetic resonance imaging (MRI) to investigate apparently isolated nystagmus noted within the first few years of life.

METHODS

Retrospective institutional review of such children (up to 5 years old).

RESULTS

Twenty-six patients (17 boys, 9 girls) were identified. Nystagmus was clinically bilateral in 22 (85%) and unilateral in 4 (15%). Seventeen cases (65%) were described as horizontal pendular nystagmus, 5 (19%) as horizontal jerk nystagmus, 2 (8%) as vertical pendular nystagmus, and 1 each as downbeat nystagmus and torsional nystagmus (8%). Three of the 26 patients (12%) had significant MRI findings and all three had temporal optic nerve head pallor noted during clinical examination. Nystagmus was horizontal pendular in two patients and rotary in the third.

CONCLUSION

The optic nerve head should be carefully assessed for signs of pallor in young children with nystagmus and, if present, brain MRI should be performed. Otherwise, isolated early childhood nystagmus is unlikely to be associated with intracranial pathology. Clinical description of nystagmus did not predict intracranial pathology in this cohort.

What we know about the generation of nystagmus and other ocular oscillations: are we closer to identifying therapeutic targets?

Mechanisms underlying acquired nystagmus are better understood than those leading to infantile nystagmus. Accordingly, further progress has been made in the development of effective therapies for acquired nystagmus, mainly through pharmacological interventions. Some of these therapies have been developed under the guidance of findings from experimental animal models. Although mechanisms behind infantile nystagmus are less understood, progress has been made in determining the genetic basis of nystagmus and characterizing associated sensory deficits. Pharmacological, surgical, and other treatments options for infantile nystagmus are now emerging. Further investigations are required for all forms of nystagmus to produce high-quality evidence, such as randomized controlled trials, upon which clinicians can make appropriate treatment decisions.