Alexander's law and the oculomotor neural integrator: three-dimensional eye velocity in patients with an acute vestibular asymmetry

Alexander's Law During High-Speed, Yaw-Axis Rotation: Adaptation or Saturation?

Objective: Alexander's law (AL) states the intensity of nystagmus increases when gaze is toward the direction of the quick phase. What might be its cause? A gaze-holding neural integrator (NI) that becomes imperfect as the result of an adaptive process, or saturation in the discharge of neurons in the vestibular nuclei? Methods: We induced nystagmus in normal subjects using a rapid chair acceleration around the yaw (vertical) axis to a constant velocity of 200°/second [s] and then, 90 s later, a sudden stop to induce post-rotatory nystagmus (PRN). Subjects alternated gaze every 2 s between flashing LEDs (right/left or up/down). We calculated the change in slow-phase velocity (ΔSPV) between right and left gaze when the lateral semicircular canals (SCC) were primarily stimulated (head upright) or, with the head tilted to the side, stimulating the vertical and lateral SCC together. Results: During PRN AL occurred for horizontal eye movements with the head upright and for both horizontal and vertical components of eye movements with the head tilted. AL was apparent within just a few seconds of the chair stopping when peak SPV of PRN was reached. When slow-phase velocity of PRN faded into the range of 6-18°/s AL could no longer be demonstrated. Conclusions: Our results support the idea that AL is produced by asymmetrical responses within the vestibular nuclei impairing the NI, and not by an adaptive response that develops over time. AL was related to the predicted plane of eye rotations in the orbit based on the pattern of SCC activation.

Role of neural integrators in oculomotor systems: a systematic narrative literature review

PURPOSE

To evaluate the role of neural integrators (NI) in the oculomotor system.

METHODS

A literature search was carried out using several electronic databases during the months of June 2014 to March 2015. The following keywords were used to generate focused results: 'neural integrators', 'gaze-holding', 'oculomotor integration', 'impaired gaze-holding', 'gaze evoked nystagmus' and 'gaze dysfunction'. Further materials were found through searching relevant articles within reference lists. Seventy-one articles were sourced for this review which analysed animal and human subjects and network models; 45 were studies of humans, 16 studies of primates, three studies of felines and one study from rats and network models. The remaining articles were literature reviews.

RESULTS

The horizontal and vertical, including torsional, NI are located logically in the brainstem, nearby their appropriate target extraocular motoneuron nuclei for stable eye position in eccentric position. The nucleus prepositus hypoglossi (NPH) and medial vestibular nuclei (MVN) are closely linked at the caudal pons and dorsal rostral medulla, integrating horizontal conjugate eye movement. The interstitial nucleus of Cajal (INC) integrates vertical and torsional eye movement at the upper midbrain. The integrator time constant is averaged to 25 seconds in human horizontal and animal vertical NI to perform its function. Case reports revealed that dysfunction of horizontal NI also resulted in vertical ocular deviations, indicating some overlap of horizontal and vertical gaze control. Furthermore, pharmacological inactivation of NI exposed a population of inhibitory neurotransmitters that permits its mechanism of action; allowing for smooth conjugate movement.

CONCLUSIONS

Neural integrators operate to integrate eye velocity and eye position information to provide signals to extraocular motoneurons to attain and maintain a new position. Therefore, NI allow image stabilization during horizontal and vertical eye movements at eccentric positions for comfortable single vision.

A mechanism for eye position effects on spontaneous nystagmus

In acute stages of unilateral vestibular deficit, the imbalanced tonic activity on vestibular afferents evokes spontaneous nystagmus. The slow-phase velocity of this nystagmus varies with eye position, such that it is smaller when looking in the direction of slow-phases. The neural mechanism for this behavior is still not understood. Here, using a simple control system model, we show that plausible changes in the neural responses within the central vestibulo-ocular reflex pathway are adequate to cause eye position dependent effects in the nystagmus pattern. The proposed transformations in population response functions could happen immediately following a lesion and can be useful to stabilize gaze in part of the gaze field.

Development of eye position dependency of slow phase velocity during caloric stimulation

The nystagmus in patients with vestibular disorders often has an eye position dependency, called Alexander’s law, where the slow phase velocity is higher with gaze in the fast phase direction compared with gaze in the slow phase direction. Alexander’s law has been hypothesized to arise either due to adaptive changes in the velocity-to-position neural integrator, or as a consequence of processing of the vestibular-ocular reflex. We tested whether Alexander’s law arises only as a consequence of non-physiologic vestibular stimulation. We measured the time course of the development of Alexander’s law in healthy humans with nystagmus caused by three types of caloric vestibular stimulation: cold (unilateral inhibition), warm (unilateral excitation), and simultaneous bilateral bithermal (one side cold, the other warm) stimulation, mimicking the normal push-pull pattern of vestibular stimulation. Alexander’s law, measured as a negative slope of the velocity versus position curve, was observed in all conditions. A reversed pattern of eye position dependency (positive slope) was found <10% of the time. The slope often changed with nystagmus velocity (cross-correlation of nystagmus speed and slope was significant in 50% of cases), and the average lag of the slope with the speed was not significantly different from zero. Our results do not support the hypothesis that Alexander’s law can only be observed with non-physiologic vestibular stimulation. Further, the rapid development of Alexander’s law, while possible for an adaptive mechanism, is nonetheless quite fast compared to most other ocular motor adaptations. These results suggest that Alexander’s law may not be a consequence of a true adaptive mechanism.

Invariance of vestibulo-ocular reflex gain to head impulses in pitch at different initial eye-in-orbit elevations: implications for Alexander's law

CONCLUSIONS

These findings are in line with previous data on the horizontal vestibulo-ocular reflex (VOR) from this laboratory and suggest that eye position signals do not modulate natural vestibular responses. Hence, the Alexander's law (AL) phenomenon cannot be interpreted simply as a consequence of vestibular or oculomotor nuclei activity modulation with desired gaze.

BACKGROUND

AL states that the intensity of the spontaneous nystagmus of a patient with a unilateral vestibular lesion grows with increasing gaze in the direction of the fast phase. Some of the mechanisms proposed to account for the gaze effects assume a direct modification of the normal VOR by eye position signals. We tested the validity of these assumptions and investigated the effects of gaze direction on the normal vertical human VOR in the behaviorally relevant high frequency range.

METHODS

Head and eye movements were recorded with the search coil method during passive head impulses in pitch, while subjects were asked to hold gaze at various elevation angles in 8° steps within ± 16° from the straight ahead reference position.

RESULTS

Upward and downward head rotations produced VOR gains of similar magnitude. Furthermore, the gain remained unaffected by eye-in-orbit position for both upward and downward head impulses.

Nystagmus and saccadic intrusions

We review current concepts of nystagmus and saccadic oscillations, applying a pathophysiological approach. We begin by discussing how nystagmus may arise when the mechanisms that normally hold gaze steady are impaired. We then describe the clinical and laboratory evaluation of patients with ocular oscillations. Next, we systematically review the features of nystagmus arising from peripheral and central vestibular disorders, nystagmus due to an abnormal gaze-holding mechanism (neural integrator), and nystagmus occurring when vision is compromised. We then discuss forms of nystagmus for which the pathogenesis is not well understood, including acquired pendular nystagmus and congenital forms of nystagmus. We then summarize the spectrum of saccadic disorders that disrupt steady gaze, from intrusions to flutter and opsoclonus. Finally, we review current treatment options for nystagmus and saccadic oscillations, including drugs, surgery, and optical methods. Examples of each type of nystagmus are provided in the form of figures.