Characters of nystagmus
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1 Characters of nystagmus Special types of nystagmus Ocular bobbing Ocular flutter Ocular myoclonus
2 Characters of nystagmus Special types of nystagmus Disconjugate Nystagmus Circumduction Nystagmus Nystagmus in One Eye
3 Characters of nystagmus Special types of nystagmus Vertically - Down - Beating Nystagmus Vertically - Up - Beating Nystagmus Periodic Alternating Nystagmus
4 Characters of nystagmus Special types of nystagmus See Saw Nystagmus Rebound Nystagmus Nystagmus in Abduction
5 VESTIBULO-OCULAR TESTS (contd) Tests for provoked nystagmus # gaze nystagmus test # head impulse test # positional / positioning nyst. test # labyrinthine fistula test # head-shaking nystagmus test
6 VESTIBULO-OCULAR TESTS Gaze nystagmus test:- Any nystagmus abnormally induced by looking 30 away from mid- point rt / lt / up / dn is looked for -evaluates gaze holding function -nystagmus in any position of gaze is abnormal and suggests a CNS lesion GAZE RIGHT GAZE LEFT
7 VESTIBULO-OCULAR TESTS Tests for provoked nystagmus Head Impulse test:- -evaluates the Vestibulo-Ocular Reflex (VOR) gain of the 3 semicircular canals of both sides -considered to be one of the best and most reliable bedside tests to assess labyrinthine function
8 Head Impulse test HIT normal & pathological in extreme slow motion
9 VESTIBULO-OCULAR TESTS Tests for provoked nystagmus Positional and Positioning tests:- Any nystagmus abnormally induced by change of position is looked for
10 VESTIBULO-OCULAR TESTS Tests for provoked nystagmus Fistula Test : a Seigle s speculum snugly fitted in the ext. meatus or the probe of an impedance audiometer can be used for exerting pressure in the ear Any nystagmus is looked for
11 VESTIBULO-OCULAR TESTS Tests for provoked nystagmus Head Shaking Test :- Any nystagmus abnormally induced by head shaking is looked for -pt asked to keep eyes closed and head shaken side to side for 20 times -then pt asked to immediately open the eyes -any nystagmus looked for -lt beating nystagmus suggests a rt peripheral vest lesion and vice versa
12 VOR may be jeopardized by defects in the OCULOMOTOR system viz. - Ocular malalignment /skew -Defective SMOOTH PURSUIT SYSTEM -Defective SACCADIC system -Disorders in CONVERGENCE /DIVERGENCE systems - Defective OPTOKINETIC system -Defective VOR / VORS All prevent the execution of a perfect VOR
13 Eye tests relevant to Vest. System 1) Identification of HEAD TILT and OTR Head Tilt Contraversive tilt - lesions in medial long. fasciculus - superior oblique muscle paresis Ipsiversive tilt - peripheral vest. lesions - lower ponto-medullary lesions
14 2) Test for Heterotropia COVER test (to detect misalignment of visual axes) - fixate vision at distant target (20 ft) - one eye covered - any movement of other eye looked for while pt. fixates eye continuously on distant target + ve test indicates OCULAR MISALIGNMENT / ABNORMAL SKEW
15 3)Test for SMOOTH PURSUIT - pt. visually tracks a target moving at /sec 18 inches in front horizontally & vertically - any jerky eye movement looked for - presence of saccades indicate a disorder in the smooth pursuit system (e.g., cerebellar disorder like spinocerebellar ataxia)
16 Patient looks back and forth between 2 objects (examiner`s fingers) placed 2 ft. away from each other in horizontal and vertical axes - To look for - any to & fro eye movement on reaching target before fixation - any oscillation Abnormality suggests central vestibular lesion 4)SACCADE test Eye movement in normal saccade test
17 5) VERGENCE test - Examiner holds index finger 18 inches in front of patient`s eyes - Slowly brings the finger towards patient`s bridge of nose Normal response - near vision triad viz. - eyes converge towards midline - accommodation for near vision - pupillary constriction Absence of any one suggests VERGENCE disorder
18 HINTS- a clinical test based on derangement of otolithic pathways Very useful clinical test in ER for patients presenting with acute vertigo called Acute Vestibular Syndrome (AVS) Used to differentiate Cerebellar Stroke Vs Vestibular Neuritis in patients presenting with acute vestibular symptoms HINTS examination is more sensitive than MRI in detecting cerebellar stroke in first 48hrs in patients (Newman-Toker 2013) Anirban Biswas, Neurotologist
19 HINTS Test- a combination of 3 tests HI Horizontal Head Impulse Impulse Normal N Nystagmus Fast-phase Alternating TS Test of Skew Refixation in (alternate) Cover Test Anirban Biswas, Neurotologist
20 ABCD2 Risk Score for Stroke Five-item ABCD2 risk score Stroke score Age A 60 years = 1 Blood pressure B systolic 140 or diastolic /90 = 1 Clinical features C unilateral weakness = 2, speech disturbance without weakness = 1, any other symptom = 0 Duration of symptoms D <10 min = 0; min = 1; 60 min = 2 Diabetes D present = 1 SCORE of 4 or more is indicative of a risk of STROKE
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