Pursuit eye movements in a patient with a lesion involving the vestibular nuclear complex

Abnormal supranuclear eye movements in the child: a practical guide to examination and interpretation

Abnormal eye movements in the infant or voting child can be congenital or acquired. They may be a result of abnormal early visual development or a sign of underlying neurologic or neuromuscular disease. It is important to be able to detect these abnormalities and to distinguish them from normal but immature eye movements. The spectrum of disease in children differs from that in adults. Serious, potentially fatal but treatable disorders can be acquired in infancy, and abnormal eye movements in a sometimes apparently well child should never be labeled as congenital or benign without careful investigation. Eye movement analysis can indicate the presence of an underlying condition and help the clinician to classify different neurologic diseases. It is important to carefully examine the ocular motor system in any children at risk of neurologic disease. This review provides a practical guide to the examination and interpretation of eye movements in the child and includes recent literature on eye movement disorders of childhood. We describe supranuclear abnormalities of the ocular motor system in the order in which we would normally examine it: saccades, pursuit, convergence, vestibulo-ocular reflex, and optokinetic nystagmus. Nystagmus, internuclear ophthalmoplegia, cranial nerve abnormalities, and "miswiring" phenomena (such as Duane's syndrome and synergistic divergence) are not discussed.

Unilateral saccadic pursuit in patients with sensory stroke: sign of a pontine tegmentum lesion

BACKGROUND AND PURPOSE

Pure hemisensory syndrome can be caused by small strokes occurring in a number of regions, including the thalamus and pons. Differentiation of the pontine sensory syndrome from the thalamic sensory syndrome has generally been made on the basis of distribution of sensory loss and involvement of specific sensory modalities but not without uncertainties and difficulties. Because the pontine tegmentum plays a pivotal role in generating horizontal eye movement, we attempted to discriminate these 2 syndromes by analyzing horizontal eye movements in stroke patients with pure hemisensory syndrome.

METHODS

Horizontal saccade, pursuit, vestibulo-ocular reflex (VOR), and VOR cancellation (VORC) were evaluated using electro-oculography in 6 patients with hemisensory syndromes, 3 due to pontine stroke and 3 due to thalamic stroke, and all were verified by MRI or CT. In addition, somatosensory evoked potentials (SEPs) were recorded.

RESULTS

Smooth pursuit and VORC directed toward the side of the lesion were impaired unilaterally in patients with pontine sensory stroke, whereas those 2 movements were intact bilaterally in patients with thalamic sensory stroke. Saccade and VOR were preserved in all patients. SEPs were normal in all patients with pontine and thalamic sensory strokes. No difference was found in the pattern of sensory disturbance between the 2 types of stroke patients.

CONCLUSIONS

Ipsilateral impairment of the smooth pursuit system may be a sign of a pontine lesion in patients with hemisensory stroke.

Vestibulo-ocular reflex abnormality in Vogt-Koyanagi-Harada syndrome

The eye movements of 15 patients with Vogt-Koyanagi-Harada (VKH) syndrome were analysed. Transient dizziness occurred in 60% of the patients. Eight patients (53%) exhibited horizontal jerk nystagmus that was completely inhibited by visual fixation. Eight cases (53%) exhibited the elevation of vestibulo-ocular reflex (VOR) gain in darkness. Six of the patients with nystagmus had defective smooth pursuit movements with reduced gain on the side ipsilateral to the nystagmus. Saccadic and optokinetic eye movements were intact, and visual vestibular interaction was also normal. Impaired eye movements in VKH syndrome may be caused by asymmetry of the vestibular function secondary to the labyrinthine inflammation.

Paresis of contralateral smooth pursuit and normal vestibular smooth eye movements after unilateral brainstem lesions

Pursuit and vestibular smooth eye movements were measured in patients with lesions of the caudal brainstem tegmentum identified by magnetic resonance imaging (MRI) and computed tomography (CT), with neuropathological correlation in 1 patient. Contralateral smooth pursuit gain was significantly lower than ipsilateral gain in each patient. Ipsilateral smooth pursuit gain was also subnormal in patients with unilateral pontine damage that caused slowing of ipsilateral saccades. Horizontal vestibulo-ocular reflex gain and phase were normal. These quantitative correlations indicate that lesions of the pontine tegmentum that paralyze ipsilateral saccades can spare the vestibulo-ocular reflex, and that smooth pursuit movement and the vestibulo-ocular reflex can be impaired independently by pontine or medullary lesions. In contrast to lesions at other sites, unilateral lesions of the pontine or medullary tegmentum impair contralateral smooth pursuit more than ipsilateral pursuit movements. These findings provide evidence that a double decussating pathway mediates smooth pursuit; the first decussation is from the pons to the cerebellum, and the second decussation is from the vestibular nucleus to the contralateral abducens nucleus.

Oculomotor functions of the flocculus and the vestibular nuclei after bilateral vestibular neurectomy

Ito's hypothesis of an important role of the flocculus of the vestibulocerebellum in the immediate visual control of the VOR during visual-vestibular interaction has received substantial support. Nevertheless, several parts in this hypothesis are unclear, at least in primates. In normal monkey, vestibularly driven neurones in the vestibular nuclei do not carry signals which are adequate to account for the full range of eye movement responses during optokinetic tracking (OKN) and different situations of visual-vestibular interaction (especially VOR-suppression). Thus these neurones seem not to be located at the final stage where floccular "gaze-velocity" Purkinje cells (PCs) exert their control function on the three-neurone-reflex arc. The signals of these "central" vestibular neurones (if relevant for the oculomotor output) must further be processed. After bilateral vestibular neurectomy (BVN) only a small number of vestibular nuclei neurones were found with eye velocity sensitivities during smooth pursuit tracking (SP) and OKN in the range of those of floccular PCs (also after BVN), and with the appropriate polarity of modulation. Our difficulties in finding neurones in the vestibular nuclei which, according to their neurophysiological behaviour, could be main target cells of floccular PCs, either in normal or in BVN monkeys, are discussed.