E-table 1
Differential diagnosis of oscillopsia
Disease/symptom /Important causes
/Typical history/exam
/Investigations
Bilateral vestibulopathy / - idiopathic- aminoglycoside treatment
- bilateral acoustic neuroma / Hx: oscillopsia only when walking, better upon standing still, no oscillopsia when sitting
Ex: pathological HTT bilaterally / patient history, neurological examination, neuro-ophthalmological exam, MRI, ENG, VEMP, audiogram
Congenital nystagmus / - sporadic
- inherited / Hx: begins in childhood, mostly normal vision
Ex: mainly horizontal nystagmus which increases with fixation or attention, usually conjugate, suppresses on convergence, neutral zone where nystagmus is absent, disturbed or perverted OKN, often accompanied by head shaking / patient history, family history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI
DBN / - idiopathic
- cerebellar degeneration
- craniocervical malformation
- cerebellar lesions
- toxic (antiepileptics, lithium, ethanol)
- metabolic (vitamin B12)
- episodic ataxia type II / Hx: blurred vision worse in the morning or when looking down, to the right or to the left, forward falls
Ex: DBN in primary position, increased with downward and lateral gaze, poorly suppressed by fixation, horizontal gaze-evoked nystagmus, deficient vertical smooth pursuit, decreased vertical OKN, disturbed visual fixation suppression of the VOR / patient history, family history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI, for further investigations see E-table 3
Gaze-evoked nystagmus / - cerebellar degeneration
- cerebellar lesions
- brainstem lesions
- intoxication (entiepileptics, ethanol)
- encephalitis
- Wernecke´s encephalopathy
- episodic ataxia type II / Hx: symptoms only in specific gaze direction
Ex: no nystagmus in primary gaze position, persisting nystagmus in one/several directions of gaze, fast phase of nystagmus is in gaze direction, after eyes are returned to central position a short-lived nystagmus in the opposite direction can occur (rebound nystagmus), often associated with smooth pursuit deficits / patient history, neurological examination, neuro-ophthalmological exam, search coil, MRI, MR angiography, doppler/duplex sonography, EKG, echocardiograph, evoked potentials, lumbar puncture, laboratory testing
Opsoclonus/
ocular flutter / - paraneoplastic with SCLC
- brainstem lesion
- cerebellar lesion
- toxic
- metabolic
- parainfectious
- hydrocephalus
- systemic disease such as AIDS, sarcoid, hepatitis / Ex: conjugated saccades without intersaccadic interval, opsoclonus is often accompanied by myoclonus / patient history, neurological and general clinical examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI, MR angiography, whole-body CT scan, doppler/duplex sonography, EKG, echocardiograph, evoked potentials, lumbar puncture, laboratory testing
Pendular nystagmus / - brainstem lesion
- Whipple´s disease
- spinocerebellar degeneration
- hypoxic / Ex: to and fro movement of the eyes, often worsened with fixation, phase shift between the eyes may exist, trajectories may be conjugate or disconjugate / patient history, family history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI, MR angiography, doppler/duplex sonography, EKG, echocardiograph, endoscopy, evoked potentials, lumbar puncture, laboratory testing
Periodic alternating nystagmus / - craniocervical malformation
- cerebellar degeneration
- cerebellar lesion
- brainstem lesion
- Creutzfeld-Jacob disease
- toxic
- trauma / Ex: mostly horizontal, not or little suppressed by visual fixation / patient history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI, MR angiography, doppler/duplex sonography, EKG, echocardiograph, evoked potentials, lumbar puncture, laboratory testing
Peripheral vestibular nystagmus / - vestibular neuritis
- Menière´s disease
- BPPV / Hx: symptoms occur in episodes or attacks and are always accompanied by severe vertigo, nausea, vomiting
Ex: spontaneous, horizontal nystagmus with rotatory component, suppressed with visual fixation, increase of nystagmus with gaze in direction of fast phase, increase or precipitated with changes in head position / patient history, neurological examination, neuro-ophthalmological exam, positioning manoeuvres, MRI, AEP, VEMP, ENG, audiogram
Seesaw nystagmus or hemi-seesaw nystagmus / - tumors in the sella region
- brainstem lesion
- craniocervical malformations
- syringobulbia
- head trauma
- whole brain irradiation / Ex: vertical-rotatory spontaneous nystagmus, one eye moves up and rotates inward, the other eye moves down and rotates outward / patient history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI, MR angiography, doppler/duplex sonography, EKG, echocardiograph, evoked potentials, lumbar puncture, laboratory testing
Upbeat nystagmus / - brainstem lesions (mesencephalic or ponto-medullary)
- cerebellar lesions
- cerebellar degeneration
- nicotine
- Creutzfeld-Jakob disease
- Wernecke´s encephalopathy
- Behcets´s disease / Hx: blurred vision worse when looking up
Ex: spontaneous nystagmus present in primary gaze position, usually increased when looking up, not suppressed by fixation, often associated with smooth pursuit deficits / patient history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, MRI, MR angiography, doppler/duplex sonography, EKG, echocardiograph, endoscopy, evoked potentials, lumbar puncture, laboratory testing
Voluntary nystagmus / - psychosomatic
- psychiatric / Ex: small amplitude saccades, no slow and fast phase can be determined, often induced by vergence eye movements, occurs in series, often associated with eye-lid flutter / patient history, neurological examination, neuro-ophthalmological exam, scanning laser ophthalmoscope, search coil, psychological testing
E-table 1. Ocular motor and vestibular disturbances causing oscillopsia listed in alphabethical order. Lesions of the brainstem and cerebellum include demyelinating disease but also ischemic lesions, infections or tumors. While we have listed the most helpful diagnostic tools for each condition, it is necessary to adapt the tests to the individual patient. (AEP = acoustic evoked potentials, BPPV = benign paroxysmal positioning vertigo, CT = computer tomography, DBN = downbeat nystagmus, EKG = electrocardiogram, ENG= electronystagmography, Ex = clinical examination, HTT = head-thrust test, Hx = patient history, MRI= magnetic resonance imaging, SCLC = small cell lung cancer, VEMP = vestibular-evoked myogenic potentials). In part adapted from (6).