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Author(s): Jonathan D. Trobe, M.D. License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self- diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.

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CLINICAL FEATURES OF VISUAL AND OCULAR MOTOR DISORDERS Jonathan D. Trobe, MD Departments of Ophthalmology and Neurology University of Michigan Medical School Fall, 2008

Source Undetermined

Nikki Selewski

Source Undetermined

Nikki Selewski

Image of a doctor performing a visual field exam was removed.

Image of a doctor performing an eye exam was removed.

Source Undetermined

Ocular Motor System 1. Move the Eyes from One Equidistant Target to Another (“Saccades”) 2. Move the Eyes from Distant to Near Target or Vice Versa (“Vergence”) 3. Keep the Eyes on Target When the Target Moves (“Pursuit”) 4. Keep the Eyes on Target When the Head Moves (“Vestibulo-ocular”)

Saccades 1. Voluntary a. Move eyes to target seen in peripheral field (“visually guided”) b. Move eyes to unseen target (“non visually guided”) 2. Involuntary a. Rapid eye movements of sleep b. Fast phases of nystagmus c. Random

Saccades Test by having patient fixate a stationary target and then look from one target to another Note whether eyes are still during fixation, and note speed, amplitude, accuracy of refixations, and if oscillations are present

Source Undetermined

Saccadic Disorders 1.Absent (gaze palsy) 2.Reduced amplitude (“hypometric”) 3.Slow 4.Inaccurate (“dysmetric”) 5.Intrusive

Vergence 1. Move eyes closer to one another (“convergence”) 2. Move eyes farther apart from one another (“divergence”)

Vergence Test by measuring ocular alignment when eyes are focusing on a distant and on a near target

Vergence Pathway 1.Generated in both parieto-occipital regions 2.Travels to midbrain 3.Exact pathway not known

Vergence Disorders Excessive convergence Insufficient convergence Excessive divergence Insufficient divergence

Vergence Disorders 1. Excessive convergence a. Congenital defect b. Too much accommodation c. Loss of vision d. Nonspecific brain insult 2. Insufficient convergence a. Idiopathic b. Nonspecific brain insult

Vergence Disorders 1.Excessive Divergence a. Congenital defect b. Loss of vision 2. Insufficient Divergence a. Nonspecific brain insult

Pursuit Test by having patient follow a moving light or finger at about 30 degrees/second Note smoothness of motion, amplitude of excursion, presence of oscillations

Source Undetermined

Pursuit Disorders 1.Cogwheel (“saccadic”) 2.Absent

Vestibulo-ocular In awake patients with intact voluntary eye movements, can test only with special techniques

Vestibulo-ocular In comatose patients and in awake patients with poor voluntary eye movements, two tests: 1. Doll’s Head Maneuver. Move head rapidly and look for slow contraversive conjugate eye movements 2. Cold Water Calorics. Look for ipsiversive slow conjugate eye movements and perhaps contraversive involuntary saccades (“nystagmus”)

Source Undetermined

Vestibulo-ocular Disorders General hypofunction (creates oscillopsia) Imbalance (creates nystagmus)

Supranuclear Gaze Palsy Absent voluntary gaze (saccades and pursuit) Intact reflex gaze (vestibulo-ocular), elicited by Doll’s Head Maneuver or Cold Water Calorics Means that brain stem gaze pathways are intact but cerebral gaze pathways are not intact

Additional Source Information for more information see: Slide 4 – Source Undetermined Slide 5 – Source Undetermined Slide 6 – “Mountain View” Nikki Selewski Creative Commons Attribution License Slide 7 – “Blurry Mountain View” Nikki Selewski Creative Commons Attribution License Slide 8 – Source Undetermined Slide 9 – Source Undetermined Slide 10 – Source Undetermined Slide 11 – Source Undetermined Slide 12 – “Obstructed Mountain View” Nikki Selewski Creative Commons Attribution License Slide 13 – “Half of a Mountain View” Nikki Selewski Creative Commons Attribution License Slide 16 – Source Undetermined Slide 17 – Source Undetermined Slide 18 – Source Undetermined Slide 19 – Source Undetermined Slide 20 – Source Undetermined Slide 21 – Source Undetermined Slide 22 – Source Undetermined Slide 23 – Source Undetermined

Slide 24 – Source Undetermined Slide 25 – Source Undetermined Slide 26 – Source Undetermined Slide 27 – Source Undetermined Slide 28 – Source Undetermined Slide 29 – Source Undetermined Slide 33 – Source Undetermined Slide 34 – Source Undetermined Slide 35 – Source Undetermined Slide 36 – Source Undetermined Slide 45 – Source Undetermined Slide 49 – Source Undetermined Additional Source Information for more information see: