Acute Cerebral Horizontal Gaze Deviation

    • Sudden onset of sustained horizontal gaze deviation produced by a cerebral lesion
    • Right gaze deviation is more common than left gaze deviation
    • Right gaze deviation is associated with a right cerebral hemisphere lesion
    • Left gaze deviation is associated with a left cerebral hemisphere lesion
    • Common cause: fronto-parietal infarct
      or hemorrhage
    • Uncommon cause: focal seizure
    • Cerebral hemispheric infarct/hemorrhage
      • Eyes deviate conjugately to the side of the lesion (“horizontal gaze deviation”)
      • Eyes may move to the midline or even to the opposite side with arousal and encouragement (“gaze preference”)
      • Doll’s eye maneuver may bring eyes to the opposite side
      • Vertical eye movements are usually intact but may be difficult to elicit
      • Hemispatial neglect is present on the side opposite to the lesion
      • Hemiparesis is present on the side opposite to the lesion
      • Low arousal state
      • MRI shows a cerebral hemispheric lesion on the side of the gaze deviation or preference
    • Focal seizure
      • Eyes deviate conjugately to the side opposite to the seizure focus
      • Jerk nystagmus with its fast phase to the side opposite to the seizure focus
      • Head is often turned to the side opposite to the seizure focus
      • Tonic-clonic movements of the limbs and face on the side opposite to the seizure focus
      • In the post-ictal period, the eyes are often conjugately deviated to the side of the seizure focus and consciousness may be temporarily impaired
      • Electroencephalography discloses hemispheric epileptic activity during a seizure and discloses hemispheric slowing post-ictally on the side of the seizure focus
    • Pontine tegmental lesion on the side opposite to the gaze deviation and hemiparesis
    • Tip: in pontine gaze palsy, the vestibulo-ocular reflex fails to move the eyes across the midline to the opposite side
    • Ocular lateropulsion: eyes deviate toward the side of a recent medullary lesion
    • Look for the following signs that help to distinguish these four entities
      • Cerebral infarct/hemorrhage
        • Hemiparesis on the side opposite to the gaze deviation
        • Doll’s eye maneuver and cold water caloric irrigation move the eyes to the opposite side
        • Hemispatial neglect on the side opposite to the lesion
      • Cerebral focal seizure
        • Head deviation to the side opposite to the seizure focus
        • Tonic-clonic extremity movements on the side of the gaze deviation
        • Eye deviation reverses direction post-ictally
      • Pontine tegmental dysfunction
        • Hemiparesis on the side of the gaze deviation
        • Doll’s eye maneuver and cold water caloric irrigation do not move the eyes to the opposite side
        • Other signs of pontine dysfunction (lower motor neuron facial weakness, nystagmus, ataxia) will usually be present
      • Medullary lesion causing ocular lateropulsion
        • Gaze deviation most pronounced under closed lids
        • Have patients close their eyes; as they open them, you will see that the eyes were deviated toward the side of the lesion but move quickly back to straight-ahead gaze position; this phenomenon occurs most commonly in dorsolateral medullary infarction (See Dorsolateral Medullary (Wallenberg) Syndrome
    • Depends on the underlying cause

    Cerebral Ocular Motor Disorders

    Congenital Ocular Motor Apraxia Acquired Ocular Motor Apraxia Acute Cerebral Horizontal Gaze Deviation Spasm of the Near Reflex