Diagnosing disconjugate eye movements: phase-plane analysis of horizontal saccades

Accuracy of clinical versus oculographic detection of pathological saccadic slowing

Saccadic slowing as a component of supranuclear saccadic gaze palsy is an important diagnostic sign in multiple neurologic conditions, including degenerative, inflammatory, genetic, or ischemic lesions affecting brainstem structures responsible for saccadic generation. Little attention has been given to the accuracy with which clinicians correctly identify saccadic slowing. We compared clinician (n = 19) judgements of horizontal and vertical saccade speed on video recordings of saccades (from 9 patients with slow saccades, 3 healthy controls) to objective saccade peak velocity measurements from infrared oculographic recordings. Clinician groups included neurology residents, general neurologists, and fellowship-trained neuro-ophthalmologists. Saccades with normal peak velocities on infrared recordings were correctly identified as normal in 57% (91/171; 171 = 9 videos × 19 clinicians) of clinician decisions; saccades determined to be slow on infrared recordings were correctly identified as slow in 84% (224/266; 266 = 14 videos × 19 clinicians) of clinician decisions. Vertical saccades were correctly identified as slow more often than horizontal saccades (94% versus 74% of decisions). No significant differences were identified between clinician training levels. Reliable differentiation between normal and slow saccades is clinically challenging; clinical performance is most accurate for detection of vertical saccade slowing. Quantitative analysis of saccade peak velocities enhances accurate detection and is likely to be especially useful for detection of mild saccadic slowing.

Transition in eye gaze as a predictor of emergence from general anesthesia in children and adults: a prospective observational study

BACKGROUND

It is useful to monitor eye movements during general anesthesia, but few studies have examined neurological finding of the eyes during emergence from general anesthesia maintained with short-acting opioids and volatile anesthetics.

METHODS

Thirty children aged 1-6 years and 30 adults aged 20-79 years were enrolled. Patients received general anesthesia maintained with sevoflurane and remifentanil. The timing of three physical-behavioral responses-eye-gaze transition (the cycle from conjugate to disconjugate and back to conjugate), resumption of somatic movement (limbs or body), and resumption of respiration-were recorded until spontaneous awakening. The primary outcome measure was the timing of the physical-behavioral responses. Secondary outcome measures were the incidence of eye-gaze transition, and the bispectral index, concentration of end-tidal sevoflurane, and heart rate at the timing of eye-gaze transition.

RESULTS

Eye-gaze transition was evident in 29 children (96.7%; 95% confidence interval, 82.8-99.9). After the end of surgery, eye-gaze transition was observed significantly earlier than resumption of somatic movement or respiration (472 [standard deviation 219] s, 723 [235] s, and 754 [232] s, respectively; p < 0.001). In adults, 3 cases (10%; 95% CI, 0.2-26.5) showed eye-gaze transition during emergence from anesthesia. The incidence of eye-gaze transition was significantly lower in adults than in children (p < 0.001).

CONCLUSION

In children, eye-gaze transition was observed significantly earlier than other physical-behavioral responses during emergence from general anesthesia and seemed to reflect emergence from anesthesia. In contrast, observation of eye gaze was not a useful indicator of emergence from anesthesia in adults.

Properties of rapid eye movements

This chapter describes the metrics and kinematics of saccades and quick phases of nystagmus, including microsaccades and large eye-head saccades. Small saccades often display dynamic overshoot, predominantly in the abducting eye. Although the function of these overshoots is unclear, the return movement is saccadic in nature. The saccade kinematics can be quantified by stereotyped relations between amplitude, duration, peak eye velocity, and peak acceleration, which vary somewhat with the initial eye position and saccade direction (centripetal vs centrifugal), possibly due to ocular plant characteristics. Saccades in a structured light environment are considerably faster than when executed in total darkness, although the origin for this facilitation is not known. The horizontal and vertical components of slant saccades are coupled, approximately matching their durations, for which possible underlying neural mechanisms are discussed. The chapter closes with a cross-species comparison of saccade characteristics.

Assessment of Saccadic Velocity at the Bedside

Saccades are a key component for the assessment and diagnosis of Neuro-ophthalmological disorders. Traditionally, clinicians have been taught to use large amplitude saccades (LAS) to assess saccadic velocity (SV), when small amplitude saccades (SAS) may be more effective. This study aimed to evaluate the advantages of SAS over LAS by presenting a video to 108 clinicians where both methods were used to assess a patient with a unilateral partial 6th nerve palsy. SAS was the preferred method in identifying the 6th nerve palsy by 43/55 (78.2%) of Neurologists, and 36/53 (67.9%) of Ophthalmologists. These findings indicate that SAS may be a more effective method than LAS for determining SV.

Differences in eye movement range based on age and gaze direction

PURPOSE

To determine the range of eye movement in normal human subjects and to investigate the effect of age and gaze direction on eye movement.

PATIENTS AND METHODS

A prospective observational study. We enrolled 261 healthy subjects, 5-91 years of age. Photographs were obtained in the cardinal gaze positions and processed using Photoshop. The processed images were analyzed using the Image J program to measure the angle of eye movement. The angle of eye movement was quantified using a modified limbus test. We measured the angle of eye movement in adduction, abduction, elevation, and depression.

RESULTS

The ranges of eye movement were 44.9 ± 7.2° in adduction, 44.2 ± 6.8° in adduction, 27.9 ± 7.6° in elevation, and 47.1 ± 8.0° in depression. The ranges of eye movement in the younger group were higher than that in the older group in adduction, abduction, and elevation (P < 0.001, P = 0.013, and P < 0.001, respectively), except in depression (P = 0.790). There were significant negative correlations between the angles of horizontal and upward gazes and age (R = -0.294 in adduction, R = -0.355 in abduction, and R = -0.506 in elevation, all P < 0.001). However, the angle of downward gaze was not significantly correlated with age (R = 0.017, P = 0.722).

CONCLUSIONS

The angle of upward gaze most rapidly decreased with age than the angle of other gaze. Unlike the age-related decline of range in horizontal and upward gazes, only downward gaze was not impaired by increasing age. Differences in eye movement range based on gaze direction and their associated aging mechanisms should be considered when assessing eye movements.

Eye Movement Abnormalities in Multiple Sclerosis: Pathogenesis, Modeling, and Treatment

Multiple sclerosis (MS) commonly causes eye movement abnormalities that may have a significant impact on patients’ disability. Inflammatory demyelinating lesions, especially occurring in the posterior fossa, result in a wide range of disorders, spanning from acquired pendular nystagmus (APN) to internuclear ophthalmoplegia (INO), among the most common. As the control of eye movements is well understood in terms of anatomical substrate and underlying physiological network, studying ocular motor abnormalities in MS provides a unique opportunity to gain insights into mechanisms of disease. Quantitative measurement and modeling of eye movement disorders, such as INO, may lead to a better understanding of common symptoms encountered in MS, such as Uhthoff’s phenomenon and fatigue. In turn, the pathophysiology of a range of eye movement abnormalities, such as APN, has been clarified based on correlation of experimental model with lesion localization by neuroimaging in MS. Eye movement disorders have the potential of being utilized as structural and functional biomarkers of early cognitive deficit, and possibly help in assessing disease status and progression, and to serve as platform and functional outcome to test novel therapeutic agents for MS. Knowledge of neuropharmacology applied to eye movement dysfunction has guided testing and use of a number of pharmacological agents to treat some eye movement disorders found in MS, such as APN and other forms of central nystagmus.

Neuromuscular transmission failure in myasthenia gravis: decrement of safety factor and susceptibility of extraocular muscles

An appropriate density of acetylcholine receptors (AChRs) and Na(+) channels (NaChs) in the normal neuromuscular junction (NMJ) determines the magnitude of safety factor (SF) that guarantees fidelity of neuromuscular transmission. In myasthenia gravis (MG), an overall simplification of the postsynaptic folding secondary to NMJ destruction results in AChRs and NaChs depletion. Loss of AChRs and NaChs accounts, respectively, for 59% and 40% reduction of the SF at the endplate, which manifests as neuromuscular transmission failure. The extraocular muscles (EOM) have physiologically less developed postsynaptic folding, hence a lower baseline SF, which predisposes them to dysfunction in MG and development of fatigue during "high performance" eye movements, such as saccades. However, saccades in MG show stereotyped, conjugate initial components, similar to normal, which might reflect preserved neuromuscular transmission fidelity at the NMJ of the fast, pale global fibers, which have better developed postsynaptic folding than other extraocular fibers.

The disturbance of gaze in progressive supranuclear palsy: implications for pathogenesis

Progressive supranuclear palsy (PSP) is a disease of later life that is currently regarded as a form of neurodegenerative tauopathy. Disturbance of gaze is a cardinal clinical feature of PSP that often helps clinicians to establish the diagnosis. Since the neurobiology of gaze control is now well understood, it is possible to use eye movements as investigational tools to understand aspects of the pathogenesis of PSP. In this review, we summarize each disorder of gaze control that occurs in PSP, drawing on our studies of 50 patients, and on reports from other laboratories that have measured the disturbances of eye movements. When these gaze disorders are approached by considering each functional class of eye movements and its neurobiological basis, a distinct pattern of eye movement deficits emerges that provides insight into the pathogenesis of PSP. Although some aspects of all forms of eye movements are affected in PSP, the predominant defects concern vertical saccades (slow and hypometric, both up and down), impaired vergence, and inability to modulate the linear vestibulo-ocular reflex appropriately for viewing distance. These vertical and vergence eye movements habitually work in concert to enable visuomotor skills that are important during locomotion with the hands free. Taken with the prominent early feature of falls, these findings suggest that PSP tauopathy impairs a recently evolved neural system concerned with bipedal locomotion in an erect posture and frequent gaze shifts between the distant environment and proximate hands. This approach provides a conceptual framework that can be used to address the nosological challenge posed by overlapping clinical and neuropathological features of neurodegenerative tauopathies.

The role of the medial longitudinal fasciculus in horizontal gaze: tests of current hypotheses for saccade-vergence interactions

Rapid shifts of the point of visual fixation between equidistant targets require equal-sized saccades of each eye. The brainstem medial longitudinal fasciculus (MLF) plays a cardinal role in ensuring that horizontal saccades between equidistant targets are tightly yoked. Lesions of the MLF--internuclear ophthalmoparesis (INO)--cause horizontal saccades to become disjunctive: adducting saccades are slow, small, or absent. However, in INO, convergence movements may remain intact. We studied horizontal gaze shifts between equidistant targets and between far and near targets aligned on the visual axis of one eye (Müller test paradigm) in five cases of INO and five control subjects. We estimated the saccadic component of each movement by measuring peak velocity and peak acceleration. We tested whether the ratio of the saccadic component of the adducting/abducting eyes stayed constant or changed for the two types of saccades. For saccades made by control subjects between equidistant targets, the group mean ratio (±SD) of adducting/abducting peak velocity was 0.96 ± 0.07 and adducting/abducting peak acceleration was 0.94 ± 0.09. Corresponding ratios for INO cases were 0.45 ± 0.10 for peak velocity and 0.27 ± 0.11 for peak acceleration, reflecting reduced saccadic pulses for adduction. For control subjects, during the Müller paradigm, the adducting/abducting ratio was 1.25 ± 0.14 for peak velocity and 1.03 ± 0.12 for peak acceleration. Corresponding ratios for INO cases were 0.82 ± 0.18 for peak velocity and 0.48 ± 0.13 for peak acceleration. When adducting/abducting ratios during Müller versus equidistant targets paradigms were compared, INO cases showed larger relative increases for both peak velocity and peak acceleration compared with control subjects. Comparison of similar-sized movements during the two test paradigms indicated that whereas INO patients could decrease peak velocity of their abducting eye during the Müller paradigm, they were unable to modulate adducting velocity in response to viewing conditions. However, the initial component of each eye's movement was similar in both cases, possibly reflecting activation of saccadic burst neurons. These findings support the hypothesis that horizontal saccades are governed by disjunctive signals, preceded by an initial, high-acceleration conjugate transient and followed by a slower vergence component.

Using fast eye movements to study fatigue in multiple sclerosis

OBJECTIVE

To investigate whether internuclear ophthalmoparesis (INO) due to demyelination of the medial longitudinal fasciculus (MLF) provides a model for studying the poorly understood symptom of fatigue in multiple sclerosis (MS). We asked whether repetitive horizontal saccades increased eye movement disconjugacy in patients with MS with INO, but not in healthy subjects.

METHODS

We compared conjugacy of horizontal saccades in 9 patients with INO (4 bilateral, total 13) and 8 controls during minute 1 and minute 10 of a fatigue test; we measured the ratio of abducting/adducting peak velocity (versional disconjugacy index [VDI]).

RESULTS

VDI values were greater in patients than controls. During the fatigue test, controls showed no changes of VDI, but patients did (p < 0.005) for 10/13 INOs, with increased ratios in 5 cases and a decrease in the other 5.

CONCLUSION

Fatigue-induced worsening of conjugacy was observed in milder internuclear ophthalmoparesis (INO), and may reflect deteriorated fidelity of saccadic pulse transmission along demyelinated medial longitudinal fasciculus. Improved conjugacy was observed in the more severe INOs, and may be due to adaptive mechanisms, such as recruitment of vergence to aid gaze shifts. INO may provide an accessible, reductionist model to study how decreased neural transmission influences fatigue in multiple sclerosis, how the brain adapts to it, and whether drugs may prove therapeutic.

Changes in dynamic and kinematic properties of saccades in ocular myasthenia following intravenous immunoglobulin treatment

The dynamics and kinematics of saccades in a patient with severe ocular myasthenia were studied before and after treatment with intravenous immunoglobulin (IVIG). Before therapy, horizontal saccades were hypometric, but faster than similar-sized saccades made by normal subjects. During a 5-minute test period, saccades decreased in size (fatigue effect), but remained faster than those of controls. Listing's plane of the eye with greater ophthalmoplegia was increased in thickness. After IVIG treatment, the range of eye movements improved, but saccades remained faster than those of controls. Also, no fatigue was observed and the thickness of Listing's plane was reduced toward the normal range. Increased peak velocity, despite progressive hypometria due to fatigue, supports the hypothesis that the pale global extraocular muscle fibers are relatively spared in myasthenia. Involvement of other extraocular muscle-fiber types leads to limited range of eye movements and an increase in the thickness of Listing's plane.