Nystagmus Testing and Diagnosis

Initial Observation and Testing

The American Academy of Otolaryngology-Head and Neck Surgery recommends nystagmus testing requires systematic observation of eye movements under different conditions: first observe for spontaneous nystagmus in primary gaze, then assess for latent nystagmus with monocular occlusion, and finally perform positional testing including the supine roll test for lateral canal involvement and the Dix-Hallpike maneuver for posterior canal involvement 1, 2, 3
Observe the eyes in primary position (straight ahead gaze) for spontaneous nystagmus, which may be horizontal, vertical, and/or torsional and is present constantly, as recommended by the American Academy of Ophthalmology 1, 4
Note that manifest nystagmus is typically symmetrical and may vary in magnitude, speed, and waveform depending on the direction of gaze, according to the American Academy of Ophthalmology 1, 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends the supine roll test as the preferred maneuver to diagnose lateral semicircular canal involvement 2, 3, 5
Position the patient supine with head in neutral position, then quickly rotate the head 90° to one side while observing the eyes for nystagmus, as described by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3, 5
Geotropic type (most common): Horizontal nystagmus beats toward the undermost ear, with more intense nystagmus when rolled to the affected side, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 3, 5, 6

The American Academy of Ophthalmology recommends performing sensory testing before motor testing, as motor testing can disrupt ocular alignment 1, 4
Document preferred head posture, as children with manifest-latent nystagmus often present with a head turn and hold the fixating eye in adduction, which is critical for surgical planning, according to the American Academy of Ophthalmology 1, 4
Exercise caution when performing diagnostic maneuvers in patients with cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, ankylosing spondylitis, low back dysfunction, spinal cord injuries, or morbid obesity, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3, 5, 6