Nystagmus is an involuntary, rhythmic back-and-forth movement of the eyes. A few beats at the extremes of gaze can be normal, but new nystagmus may come from the inner ear, the brain, drugs or alcohol.
Key symptoms
- Vertigo or dizziness
- Objects seem to jump or shake (oscillopsia)
- Blurred vision
- Nausea and unsteady walking
What you find on exam
- Direction: horizontal, vertical or rotatory
- Inner ear type: one direction, reduced by fixing the gaze
- Brain type: vertical or changes direction with gaze
- HINTS exam, cranial nerves, cerebellar tests and gait
- Dix-Hallpike test for positional vertigo
Tests
- Blood alcohol and drug levels such as phenytoin
- MRI of the brain if central signs or an abnormal HINTS exam
- Audiogram if there is hearing loss
Treatment basics
- Treat the cause: inner ear disease, stroke, drugs, multiple sclerosis
- Epley maneuver for posterior canal positional vertigo
- Stop or adjust the drug causing it
- Thiamine for suspected Wernicke encephalopathy
- Ophthalmology care for congenital nystagmus
Red flags
- Vertical or direction-changing nystagmus (brain cause)
- Nystagmus with headache, weakness, double vision or trouble speaking
- Confusion and unsteady gait in a heavy drinker (Wernicke encephalopathy)
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.