Neurological Disorders and Gaze Abnormalities

Introduction to Gaze Abnormalities

• Gaze abnormalities can indicate serious neurological disorders affecting the brainstem, cerebellum, or other brain structures, and require prompt neuroimaging and neurological evaluation to prevent morbidity and mortality 1, 2

Impact of Gaze Abnormalities

• Children with strabismus experience negative social judgments, and studies show decreased general health-related quality of life in children with strabismus, according to the American Academy of Ophthalmology 1
• Systemic conditions such as thyroid eye disease, myasthenia gravis, and other systemic conditions can present with ocular motility disorders, as stated by the American Academy of Ophthalmology 2

Associated Conditions

• Gaze abnormalities are frequently associated with stroke, particularly brainstem infarcts affecting gaze centers, and other conditions such as multiple sclerosis, brain tumors, progressive supranuclear palsy, Wernicke's encephalopathy, and metabolic disorders 3, 4, 5

Diagnostic Considerations

• A thorough ocular motility examination should include testing of both versions and ductions, documentation of limitations, overactions, or incomitance, assessment of pupillary involvement, evaluation of smooth pursuit and saccadic eye movements, testing for vertical gaze limitations, and assessment for nystagmus and other abnormal eye movements, as recommended by the American College of Radiology and the American Academy of Ophthalmology 3, 4
• The American College of Radiology recommends MRI brain with and without contrast as the preferred imaging modality for evaluating conjugate gaze palsy, with CT head used in acute settings and MRA/CTA for suspected vascular causes 3
• The following cranial nerve palsies should be considered in the differential diagnosis:

• Pupil-involving third nerve palsy requires urgent evaluation for posterior communicating artery aneurysm, as emphasized by the American Academy of Ophthalmology 4
• Isolated CN VI palsy may indicate increased intracranial pressure without direct nerve compression, according to the American Academy of Neurology 3
• Multiple ipsilateral cranial nerve palsies affecting CN III, IV, and VI may indicate a lesion at the cavernous sinus or orbital apex, as suggested by the American Academy of Neurology 3
• Abnormal EOM tracking may be associated with stroke, multiple sclerosis, and brain tumors, particularly brainstem lesions, according to the American College of Radiology 3
• Consider multiple sclerosis in patients with internuclear ophthalmoplegia (INO), as recommended by the American Academy of Neurology 3
• Consider progressive supranuclear palsy in patients with decreased velocity of saccades, as suggested by the American Academy of Neurology 5
• Asymmetric rigidity, alien hand, and apraxia with ophthalmoplegia may raise suspicion for corticobasal syndrome, according to the American Academy of Neurology 5