Ping Pong Gaze

    • Non-rhythmic slow conjugate horizontal movements of the eyes from side to side in a comatose patient
    • Attributed to severe bilateral cerebral damage that releases pontine horizontal gaze generators
    • Common causes: severe ischemic or metabolic insult to both cerebral hemispheres
    • Often misdiagnosed as epileptic nystagmus
    • Core clinical features
      • Conjugate slow horizontal eye movements taking the eyes from one extreme gaze position to the other
      • Tip: the slow roving horizontal eye movements may not reach the extremes of gaze and may not be regular
    • Possible accompanying clinical features
      • Patient responds only to painful tactile stimuli
    • Imaging features
      • Extensive damage to both cerebral hemispheres
      • Tip: if the brain MRI is normal, consider metabolic or toxic damage
    • Epileptic nystagmus
    • Recognize that this eye movement means severe bilateral cerebral damage
    • Trap: this eye movement abnormality is often misdiagnosed as part of a seizure
    • This is an ocular sign of a grave neurologic state that is irreversible if caused by ischemia, but possibly reversible if caused by toxic or metabolic encephalopathy

    Nystagmus-like Oscillations

    Overview Video Convergence Retraction Superior Oblique Myokymia Square Wave Jerks Saccades of Inattention Ocular Flutter and Opsoclonus Volitional Flutter Ocular Dysmetria Ocular Bobbing Ping Pong Gaze Oscillations of Internuclear Ophthalmoplegia Epileptic Oscillations