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Pseudonystagmus—clinical features and quantitative characteristics

Nature Reviews Neurology volume 6, pages 519–523 (2010)Cite this article

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Abstract

Background. A 60 year-old woman with multiple sclerosis (MS) and chronic hearing loss presented with head tremor and vestibular hypofunction, the combination of which can produce oscillopsia—a visual sensation that steady objects in the visual field are oscillating. This case highlights the fact that in patients with pseudonystagmus, oscillopsia is attributable to the association of head tremor and vestibular hypofunction.

Investigations. Eye and head movements were measured simultaneously with the search coil technique.

Diagnosis. Patients with MS can present with oscillopsia, and spontaneous pendular nystagmus is often observed in these individuals. In our patient, the oscillopsia was not due to pendular nystagmus, but rather to pseudonystagmus (of gaze) resulting from diminished compensatory vestibulo-ocular reflex responses to head tremor.

Management. A two-step strategy can be used in patients with pseudonystagmus: pharmacological treatment of head tremor, and vestibular rehabilitation to improve balance and diminish oscillopsia associated with head movement. Various health-care providers at other institutes attempted to address our patient's dystonic head tremor with botulinium toxin injections in the neck muscles; the response was unsatisfactory. We offered treatment with baclofen, which the patient did not tolerate. We also discussed the option of vestibular rehabilitation, which the patient did not pursue.

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Figure 1: Demyelinating lesions in a patient with multiple sclerosis.
Figure 2: Gaze fixation measured with the magnetic search coil system.
Figure 3: VOR responses to head impulses.
Figure 4: VOR repsonses to head tremor.

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Acknowledgements

Written consent for publication was obtained from the patient. This work was supported by NIH grant EY01849 awarded to D. S. Zee. A. G. Shaikh was supported by philanthropic funds from the vestibular laboratory at The Johns Hopkins University. We thank Mr Dale Roberts for technical assistance.

Author information

Authors and Affiliations

  1. Department of Neurology, The Johns Hopkins University, 600 North Wolfe Street, Pathology 2-210, Baltimore, 21287, MD, USA

    Aasef G. Shaikh & David S. Zee

  2. Department of Neurology, University of Maryland, 16 South Eutaw Street, 3rd Floor, Baltimore, 21201, MD, USA

    Stephen Reich

Authors
  1. Aasef G. Shaikh
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Contributions

A. G. Shaikh and D. S. Zee conducted clinical investigations, designed and performed the experiments, analyzed the data, and wrote the manuscript. S. Reich conducted the clinical investigation of the patient, arranged patient referral, and reviewed the manuscript.

Corresponding author

Correspondence to Aasef G. Shaikh.

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The authors declare no competing financial interests.

Supplementary information

Supplementary Movie 1

(MPG 4248 kb)

Supplementary Movie 2

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Supplementary Box 1

Method of investigation (DOC 26 kb)

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Shaikh, A., Reich, S. & Zee, D. Pseudonystagmus—clinical features and quantitative characteristics. Nat Rev Neurol 6, 519–523 (2010). https://doi.org/10.1038/nrneurol.2010.103

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