Oculogyric crisis
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Oculogyric crisis (OGC) is a rare sudden, paroxysmal, dystonic reaction that may manifest in response to specific drugs, particularly neuroleptics, or medical conditions, such as movement disorders. This neurological phenomenon is characterized by a sustained dystonic, conjugate, involuntary upward deviation of both eyes lasting seconds to hours. The term oculogyric is applied in reference to the simultaneous upward movement of both eyes, although the reaction may encompass a variety of additional responses.[1] The reaction is not life-threatening.[2]

For clarification, oculogyric seizures, also termed versive seizures, represent one of the manifestations of epilepsy. These seizures exhibit the same upward eye movement observed in OGC but are classified as a specific subtype of epilepsy.[3]

Signs and symptoms

Initial symptoms include restlessness, agitation, malaise, or a fixed stare. Then comes the more characteristically described extreme and sustained upward deviation of the eyes. In addition, the eyes may converge, deviate upward and laterally, or deviate downward. The most frequently reported associated findings are backwards and lateral flexion of the neck, widely opened mouth, tongue protrusion, and ocular pain. However, the condition may also be associated with intensely painful jaw spasms which may result in the breaking of a tooth. A wave of exhaustion may follow an episode. The abrupt termination of the psychiatric symptoms at the conclusion of the crisis is most striking.[4]

Other features that are noted during attacks include mutism, palilalia, eye blinking, lacrimation, pupil dilation, drooling, respiratory dyskinesia, increased blood pressure and heart rate, facial flushing, headache, vertigo, anxiety, agitation, compulsive thinking, paranoia, depression, recurrent fixed ideas, depersonalization, violence, and obscene language.[5]

In addition to the acute presentation, oculogyric crisis can develop as a recurrent syndrome, triggered by stress and by exposure to the drugs mentioned below.

Causes

Drugs that can trigger an oculogyric crisis include neuroleptics (such as haloperidol, chlorpromazine, fluphenazine, olanzapine),[6] carbamazepine, chloroquine, cisplatin, diazoxide, levodopa,[7] lithium, metoclopramide, lurasidone, domperidone, nifedipine, pemoline, phencyclidine ("PCP"),[8] reserpine, and cetirizine, an antihistamine. High-potency neuroleptics are the most common cause.

Other causes can include aromatic L-amino acid decarboxylase deficiency,[9] postencephalitic Parkinson's, Tourette's syndrome, multiple sclerosis, neurosyphilis, head trauma, bilateral thalamic infarction, lesions of the fourth ventricle, cystic glioma of the third ventricle, herpes encephalitis, kernicterus and juvenile Parkinson's disease.

Patients with procyclidine addiction or craving may simulate signs of extrapyramidal symptoms to receive procyclidine.[10]

Drug class Drug implicated
First-generation typical antipsychotics Haloperidol, chlorpromazine, flupenthixol, zuclopenthixol, fluphenazine
Second-generation atypical antipsychotics Risperidone, amisulpiride, aripiprazole, olanzapine, quetiapine, clozapine, lurasidone
Antidepressants Escitalopram, imipramine, fluvoxamine
Anticonvulsants Carbamazepine, lamotrigine, gabapentin
"Other" Chloroquine, cisplatin, diazoxide, levodopa, domperidone, cetirizine, phencyclidine, nifedipine, pemoline

Diagnosis

The diagnosis of oculogyric crisis is largely clinical and involves taking a focused history and physical examination to identify possible triggers for the crisis and rule out other causes of abnormal ocular movements.[11]

Treatment

Immediate treatment of drug-induced OGC can be achieved with intravenous antimuscarinics, such as benzatropine or procyclidine. Any causative new medication should be discontinued. The condition may also be treated with the antihistamine diphenhydramine.[12]

References

  1. ↑ Koban, Yaran; Ekinci, Metin; Cagatay, Halil Huseyin; Yazar, Zeliha (March 2014). "Oculogyric crisis in a patient taking metoclopramide". Clinical Ophthalmology. 8: 567–569. doi:10.2147/OPTH.S60041. PMC 3964159. PMID 24672222.
  2. ↑ Barow, Ewgenia; Schneider, Susanne A.; Bhatia, Kailash P.; Ganos, Christos (2017). "Oculogyric crises: Etiology, pathophysiology and therapeutic approaches". Parkinsonism & Related Disorders. 36: 3–9. doi:10.1016/j.parkreldis.2016.11.012.
  3. ↑ Tatum, William O.; Kaplan, Peter W.; Jallon, Pierre (2009). "Versive Seizures". Epilepsy A to Z: A Concise Encyclopedia. Demos Medical Publishing. pp. 360–361. ISBN 978-1-934559-55-0. Archived from the original on 2023-09-19. Retrieved 2021-03-06.
  4. ↑ Barow E, Schneider S, Asham E, Burroughs S, Bhatia K, Ganos C (March 2017). "Oculogyric crises: Etiology, pathophysiology and therapeutic approaches". Pakinsonism and Related Disorders. 36: 3–9. doi:10.1016/j.parkreldis.2016.11.012. PMID 27964831. Archived from the original on 10 July 2021. Retrieved 7 July 2021.
  5. ↑ Barow E, Schneider S, Asham E, Burroughs S, Bhatia K, Ganos C (March 2017). "Oculogyric crises: Etiology, pathophysiology and therapeutic approaches". Pakinsonism and Related Disorders. 36: 3–9. doi:10.1016/j.parkreldis.2016.11.012. PMID 27964831. Archived from the original on 10 July 2021. Retrieved 7 July 2021.
  6. ↑ Praharaj, Samir Kumar; Jana, Amlan K.; Sarkar, Sukanto; Sinha, Vinod Kumar (December 2009). "Olanzapine-Induced Tardive Oculogyric Crisis". Journal of Clinical Psychopharmacology. 29 (6): 604–606. doi:10.1097/JCP.0b013e3181c00b08. PMID 19910730.
  7. ↑ Virmani, Tuhin; Thenganatt, Mary Ann; Goldman, Jill S.; Kubisch, Christian; Greene, Paul E.; Alcalay, Roy N. (February 2014). "Oculogyric crises induced by levodopa in PLA2G6 parkinsonism-dystonia". Parkinsonism & Related Disorders. 20 (2): 245–247. doi:10.1016/j.parkreldis.2013.10.016. PMID 24182522.
  8. ↑ Tahir, Hassan; Daruwalla, Vistasp (2015). "Phencyclidine Induced Oculogyric Crisis Responding Well to Conventional Treatment". Case Reports in Emergency Medicine. 2015: 506301. doi:10.1155/2015/506301. PMC 4460230. PMID 26101673.
  9. ↑ Christoph Korenke, G; Christen, Hans-Jürgen; Hyland, Keith; Hunneman, Donald H; Hanefeld, Folker (January 1997). "Aromatic l-amino acid decarboxylase deficiency: An extrapyramidal movement disorder with oculogyric crises". European Journal of Paediatric Neurology. 1 (2–3): 67–71. doi:10.1016/S1090-3798(97)80065-7. PMID 10728198.
  10. ↑ Dooris, B; Reid, C (2000). "Feigning dystonia to feed an unusual drug addiction". J Accid Emerg Med. 17 (4): 311. doi:10.1136/emj.17.4.311. PMC 1725413. PMID 10921835.
  11. ↑ Barow E, Schneider S, Asham E, Burroughs S, Bhatia K, Ganos C (March 2017). "Oculogyric crises: Etiology, pathophysiology and therapeutic approaches". Pakinsonism and Related Disorders. 36: 3–9. doi:10.1016/j.parkreldis.2016.11.012. PMID 27964831. Archived from the original on 10 July 2021. Retrieved 7 July 2021.
  12. ↑ Liu, Grant T.; Volpe, Nicholas J.; Galetta, Steven L. (2010). "Eye movement disorders". Neuro-Ophthalmology. pp. 551–586. doi:10.1016/B978-1-4160-2311-1.00016-0. ISBN 978-1-4160-2311-1.
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