Profile of Gaze Dysfunction following Cerebrovascular Accident

Abstract

Aim. To evaluate the profile of ocular gaze abnormalities occurring following stroke. Methods. Prospective multicentre cohort trial. Standardised referral and investigation protocol including assessment of visual acuity, ocular alignment and motility, visual field, and visual perception. Results. 915 patients recruited: mean age 69.18 years (SD 14.19). 498 patients (54%) were diagnosed with ocular motility abnormalities. 207 patients had gaze abnormalities including impaired gaze holding (46), complete gaze palsy (23), horizontal gaze palsy (16), vertical gaze palsy (17), Parinaud's syndrome (8), INO (20), one and half syndrome (3), saccadic palsy (28), and smooth pursuit palsy (46). These were isolated impairments in 50% of cases and in association with other ocular abnormalities in 50% including impaired convergence, nystagmus, and lid or pupil abnormalities. Areas of brain stroke were frequently the cerebellum, brainstem, and diencephalic areas. Strokes causing gaze dysfunction also involved cortical areas including occipital, parietal, and temporal lobes. Symptoms of diplopia and blurred vision were present in 35%. 37 patients were discharged, 29 referred, and 141 offered review appointments. 107 reviewed patients showed full recovery (4%), partial improvement (66%), and static gaze dysfunction (30%). Conclusions. Gaze dysfunction is common following stroke. Approximately one-third of patients complain of visual symptoms, two thirds show some improvement in ocular motility.

Role of neural integrators in oculomotor systems: a systematic narrative literature review

“…Gaze-evoked nystagmus does consequently affect vision, reducing its clarity and perception, where objects may appear to be 'wheeling' and subjects experience vertigo. Therefore, it is important to understand NI; the mechanism and interactions with other areas of the brainstem and brain, especially to determine aetiologies when abnormalities present (B€ uttner & Grundei 1995;B€ uttner et al 2002;Helmchen et al 2002;Seo et al 2004;Dieterich et al 2005;Bockisch & Hegemann 2008;Cho et al 2008;Karatas 2009;Baier & Dieterich 2011;Kheradmand & Zee 2011;Khojasteh et al 2012;Nakamagoe et al 2012;Rowe et al 2013;Shaikh & Ghasia 2013;Kim et al 2014a).…”

“…Damage to the gaze-holding mechanisms disrupts the ability of the eyes to attain and maintain an eccentric position. Consequently, its strong network with eye movement systems, such as saccades and smooth pursuit, are also affected, giving rise to ocular motility abnormalities (B€ uttner & Grundei 1995;Rowe et al 2013;Shaikh & Ghasia 2013). This leads to visual disturbances and vestibular imbalances that are symptom producing.…”

“…Although there is great knowledge and understanding of NI, there is still a rise in case reports and studies that provide more supporting evidence and insight into other areas involved in neural integration (Rowe et al 2013;Kim et al 2014a;Patel & Zee 2014;. The structures involved in neural integration of conjugate horizontal, vertical and torsional eye movements while the head is stationary, will be discussed.…”

“…Although there is great knowledge and understanding of NI, there is still a rise in case reports and studies that provide more supporting evidence and insight into other areas involved in neural integration (Rowe et al. ; Kim et al. ; Patel & Zee ; Shaikh & Ghasia ).…”

“…The nucleus prepositus hypoglossi (NPH) and medial vestibular nuclei (MVN) integrate horizontal gaze, whereas the interstitial nucleus of Cajal (INC) integrates vertical and torsional gaze (Cannon & Robinson 1987;Crawford et al 1991;Yokota et al 1992;Mettens et al 1994;Fukushima & Kaneko 1995;Lambert & Kaneko 1995;Kaneko 1997;Moschovakis 1997;Dalezios et al 1998;B€ uttner et al 2002;Glasauer 2003;Rowe 2003;Kheradmand & Zee 2011;Leigh & Zee 2015). The cerebellum and cerebral cortical areas such as the parietal, occipital and temporal lobe have also been shown to contribute to ocular motor integration (Harris et al 1993;Karatas 2009;Rowe et al 2013;.…”