Ocular Flutter After Mild Head Trauma

Opsoclonus and ocular flutter: evaluation and management

PURPOSE OF REVIEW

Opsoclonus and ocular flutter are saccadic intrusions characterized by spontaneous, back-to-back, fast eye movements (saccades) that oscillate about the midline of central visual fixation without intervening inter-saccadic intervals. When this type of movement occurs exclusively in the horizontal plane, it is called ocular flutter. When it occurs in multiple planes (i.e. horizontal, vertical, and torsional) it is called opsoclonus. The most common etiologic categories are parainfectious and paraneoplastic diseases. Less common are toxic-metabolic, traumatic, or idiopathic origins. The mechanism of these movements relates to dysfunction of brainstem and cerebellar machinery involved in the generation of saccades. In this review, we discuss the characteristics of opsoclonus and ocular flutter, describe approaches to clinical evaluation and management of the patient with opsoclonus and ocular flutter, and review approaches to therapeutic intervention.

RECENT FINDINGS

Recent publications demonstrated eye position-dependent opsoclonus present only in left gaze, which may be related to dysfunction of frontal eye fields or structures in the cerebellar vermis.

SUMMARY

Opsoclonus and ocular flutter originate from a broad array of neuropathologies and have value from both a neuroanatomic and etiologic perspective.

Saccadic intrusions in pediatric non-accidental trauma

Purpose

To report a case of saccadic intrusions in a 9-month-old under the context of non-accidental trauma.

Observations

A 9-month-old female presented with the eye finding of intermittent ocular flutter. Upon imaging for neuroblastoma, she was discovered to have bilateral supratentorial subdural hematomas with internal septations, moderate mass effect on adjacent cerebral parenchyma, pachymeningeal and tentorial enhancement, and cortical vein thrombosis. This constellation of findings was concerning for non-accidental trauma.

Conclusions and importance

Although an extremely rare occurrence, ocular flutter may be a presenting sign in non-accidental trauma, and imaging should absolutely be considered under such circumstances.

Eye position-dependent opsoclonus in mild traumatic brain injury

Opsoclonus consists of bursts of involuntary, multidirectional, back-to-back saccades without an intersaccadic interval. We report a 60-year-old man with post-concussive headaches and disequilibrium who had small amplitude opsoclonus in left gaze, along with larger amplitude flutter during convergence. Examination was otherwise normal and brain MRI was unremarkable. Video-oculography demonstrated opsoclonus predominantly in left gaze and during pursuit in the left hemifield, which improved as post-concussive symptoms improved. Existing theories of opsoclonus mechanisms do not account for this eye position-dependence. We discuss theoretical mechanisms of this behavior, including possible dysfunction of frontal eye field and/or cerebellar vermis neurons; review ocular oscillations in traumatic brain injury; and consider the potential relationship between the larger amplitude flutter upon convergence and post-traumatic ocular oscillations.