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TIPS FOR A BETTER EYE EXAM
Emily Schmidt COT I have no relevant financial or nonfinancial relationships in the products or services described, evaluated or compared in this presentation.
HOW COMMON IS
NYSTAGMUS?
• A. 1 in 1,000
• B. 1 in 3,000
• C. 1 in 5,000
• D. 1 in 10,000
The answer may surprise you…
A. 1 in 1,000
According to the 2010 census the Minneapolis, St Paul metropolitan area
population was 3,759,978 and 7.139 billion in the world. This means there are
3,760 people in the twin cities with nystagmus and 7,139,000 worldwide.
NYSTAGMUS GROUPS
Congenital
Acquired
Sensory
Neurological
NYSTAGMUS FORMS Manifest
Latent
Manifest-Latent
KINDS OF NYSTAGMUS
NYSTAGMUS SUBTYPES 49 different subtypes
Congenital=lifelong
1 exception Spasmus Natans
Acquired=???
ASSOCIATED CONDITIONS:
CONGENITAL Congenital Cataract
Optic nerve hypoplasia
Aniridia
Severe refractive error
Retina coloboma
Other optic nerve and retina disorders
Albinism (both regular and ocular)
Fetal alcohol syndrome
Idiopathic…
Duration
ASSOCIATED CONDITIONS:
ACQUIRED Medication use
Vitamin deficiency
Trauma
Inner ear (vestibular) problems
Stroke (most common cause in older people
with acquired nystagmus
Brain tumor (rare cause of acquired
nystagmus)
Multiple sclerosis
Chiari Malformation
NEVER IDIOPATHIC!!!
H OW
DOES
SOMEONE
WITH
CONGENITAL
NYSTAGMUS
SEE THE WORLD???
TYPES OF NYSTAGMUS
MOVEMENTS
1. Vertical
1a.Upbeat
1b.Downbeat
1c.Seesaw
2.Torsional/
Rotary
3.Horizontal
3a. Horizontal
jerk
Spasmus
Natans
WAYS TO CAUSE TEMPORARY NYSTAGMUS
Rapid head shaking or spinning
Optokinetic drum or the railroad effect
NYSTAGMUS MANAGEMENT
METHODS Correct vision with Rx if needed
Glasses
Contacts
Surgery
Null point
Strabismus
Muscle/nerve disruption
Prisms
Convergence
Null point
Medications
Azopt (Brinzolamide) CN/INS
Oral medications-acquired
Botox Retrobulbar vs individual muscles
Acquired: MS, stroke, tumors
Side affects: ptosis, diplopia,
reduced accommodation
Temporary 3-6 months/2-3 months
High minus contacts with
high plus glasses
Management Approach Examples
Oral Medications
Gabapentin
Memantine
4-aminopyridine
3,4-diaminopyridine
Baclofen
Clonazepam
Valproate
Trihexyphenidyl
Benztropine
Scopolamine
Isoniazid
Carbamazepine
Barbiturates
Alcohol
Acetazolamide
Brinzolamide (topical)
Cannabis
Nystagmus Type Medication Common Side-Effects
Peripheral Vestibular
Nystagmus
Treatment of
underlying
disorder
Not applicable
Downbeat
Nystagmus
4-aminopyridine
3,4-diaminopyridine
Clonazepam
Dizziness, paresthesias,
incoordination
Dizziness, paresthesias,
incoordination
Drowsiness, dizziness, incoordination
Upbeat Nystagmus Memantine
4-aminopyridine
Baclofen
Lethargy, dizziness, headache
Dizziness, paresthesias,
incoordination
Drowsiness, dizziness, lethargy
Nystagmus Type Medication Common Side-Effects
Torsional Nystagmus Gabapentin Dizziness, incoordination, drowsiness
Seesaw Nystagmus Alcohol
Clonazepam
Memantine
Drowsiness, incoordination, vomiting
Drowsiness, dizziness, incoordination
Lethargy, dizziness, headache
Periodic Alternating
Nystagmus
Baclofen
Memantine
Drowsiness, dizziness, lethargy
Lethargy, dizziness, headache
Acquired Pendular
Nystagmus in MS
Gabapentin
Memantine
Dizziness, incoordination, drowsiness
Lethargy, dizziness, headache
Acquired Pendular
Nystagmus in OPT
Gabapentin
Memantine
Trihexyphenidy
Dizziness, incoordination, drowsiness
Lethargy, dizziness, headache
Dry mouth, blurred vision, dizziness
MANAGEMENT METHODS
SUMMARY
All methods can yield similar results
Nystagmus may be lessoned but never gone
Vision may be improve by up to 4 lines, 1 to 2
is more common, or it may not improved at all
Drugs for acquired are mainly used to reduce
or stop oscillopsia
THE EXAM… ***LISTEN TO YOUR PATIENT!!!***
Let them use their null point
Slow down, Slow down, SLOW DOWN!!!!!!!!!
THE EXAM
Low vision does not equal low IQ
Watch out for memorization
Not everyone with nystagmus has a
latent component
Let them hold the near card where they want
Always check binocular vision
OCCLUDERS Single vs double occluder???
Null point=single occluder
Large movement=single occluder
OCCLUDERS Black vs Translucent
Translucent patch occluder Clip on occluders
Handheld pinhole Clip on pinhole
PHOROPTER VS TRIAL FRAMES Null point=Trial frames
Large movement=Trial frames
Latent component=Trial frames***
Black occluder lens Pinhole lens
Plus lens
SPECIALIZED TESTS OCT, fundus photos, visual field, topography, IOL master, etc…
Breath, don’t panic
Adjust the machine to the patient
Don’t get frustrated
Use comment boxes
Accept that you may not get a perfect test
THE UNNECESSARY
“NECESSARY
TESTS” Ø Non Contact Tonometry
Ø Autorefractors
2 Common Patient Surgery Questions ? Can I have LASIK
? Can I have cataract surgery
REFERENES http://www.allaboutvision.com/conditions/nystagmus.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279675/
http://webeye.ophth.uiowa.edu/eyeforum/tutorials/Nystagmus/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1279676/
http://content.lib.utah.edu/utils/getfile/collection/ehsl-
nam/id/47/filename/image
http://www.aapos.org/terms/conditions/80
http://emedicine.medscape.com/article/1199177-overview#a0101
http://en.wikipedia.org/wiki/Nystagmus
RESOURCES FOR PATIENTS American Nystagmus Network (ANN): http://nystagmus.org/new/index.php
ANN Facebook Group
Nystagmus Network (NN) UK based: http://www.nystagmusnet.org/cms/
Nystagmus United Facebook group
