Nystagmus

  • Involuntary jerking movements of the eyes. Can occur side to side, up and down, or in a circular pattern.
  • Nystagmus can be a sign of cerebellar disease, drug toxicities, vestibular disease, multiple sclerosis or other CNS diseases.
  • In malnourished patients, alcoholics, bariatric surgery patients, and others with nystagmus, especially with gait disturbances and mental status changes, think of Wernicke’s encephalopathy, which is a medical emergency.
    • Responds to thiamine.
    • Can be induced in susceptible patients by the infusion of dextrose without thiamine.

Patient 1:

This patient has Wernicke’s encephalopathy.

Patient 2:

This is a middle-aged woman with Wernicke’s encephalopathy. Notice the presence of nystagmus, particularly on gaze to the left.

Patient 3:

This is a middle-aged man with heavy alcohol use who was admitted to the hospital with confusion and ataxic gait, and was found to have nystagmus and a positive string sign, consistent with Wernicke’s encephalopathy.

Patient 4:

This is an 80-year-old man with peripheral vascular disease who was admitted with vertigo and found to have direction-changing nystagmus on exam, consistent with a central cause. Brain imaging revealed severe stenosis of the posterior circulation as well as a pontine mass.