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Nystagmus-like Oscillations
Ping Pong Gaze
What is it?
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
What does it look like?
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
What else looks like it?
Epileptic nystagmus
What should you do?
Recognize that this eye movement means severe bilateral cerebral damage
Trap:
this eye movement abnormality is often misdiagnosed as part of a seizure
What will happen?
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