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Diseases » Nystagmus » Causes

Causes of Nystagmus



Contents

List of causes of Nystagmus

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Nystagmus) that could possibly cause Nystagmus includes:

More causes: see full list of causes for Nystagmus

Causes of Nystagmus (Diseases Database):

The follow list shows some of the possible medical causes of Nystagmus that are listed by the Diseases Database:

Source: Diseases Database

Causes of Nystagmus: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Nystagmus.

Nystagmus: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Vestibular
    –Peripheral (horizontal rotary nystagmus, slow phase toward hypoactive side, latency, fatigability, and accompanied by vertigo, tinnitus, or deafness): Etiologies include labyrinthitis, vestibular neuronitis, Ménie're's disease, migraine, BPV
    –Central (asymmetric, rotary nystagmus that changes direction in different gazes, no latency, not fatigable): Etiologies include lesions of cerebellum, pons, or cerebellopontine angle
    –Horizontal
  • Gaze-evoked
    –Physiologic: Fixing on objects with eyes when head is turned (e.g., ballerinas)
    –Pathologic (asymmetric): Etiologies include toxic-metabolic lesions, cerebellar or pontine lesions
  • Dissociated (different nystagmus between eyes): Etiologies include internuclear ophthalmoplegia of multiple sclerosis or cerebral disease
  • Periodic alternating nystagmus (cervicomedullary junction)
  • Downbeat (cervicomedullary junction, characteristic of syringobulbia)
  • Upbeat (brainstem or cerebellum when present in primary gaze; drug effect if only present in upgaze)
  • Drug-induced (e.g., anticonvulsants, sedatives, alcohol)
  • Monocular visual loss (ipsilateral slow vertical oscillation)
  • Head nodding, head turn (due to motor or sensory deficits)
    –Latent nystagmus (occurs only when one eye is viewing, and is always associated with strabismus)
    –Nystagmus blockage syndrome (convergence, esotropia, and head turn)
    –Spasmus nutans: Onset 4–14 months, resolves by age 5; head nodding, torticollis, see-saw

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Nystagmus: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

    • Nystagmus occurs at the extreme lateral gaze in many normal individuals
      –May also occur when tracking an object or row of objects horizontally
      –Can be induced by rotatory visual stimuli or otic irrigation (vestibular stimuli) in normal individuals
    • Hereditary nystagmus
      –Benign condition of horizontal nystagmus
      –May not be accompanied by other neurologic findings, but involuntary head-bobbing may be a feature
      –May be XL or AD
    • Visual impairment
      –Poor vision, ocular blindness, and cortical blindness can result in nystagmus
      –May also have “searching” eye movements that are not true nystagmus
      –Both are more likely to occur in patients born blind or blind from an early age
    • Spasmus mutans
      –May be isolated or associated with intracranial mass
      –Characterized by nystagmus, involuntary head-bobbing, and torticollis
    • Congenital jerking nystagmus
      –Idiopathic; horizontal nystagmus with lateral gaze on one direction
  • Intracranial neoplasms
  • Arnold-Chiari malformation
    • Cerebellar etiologies
      –Acute cerebellar ataxia
      –Encephalitis or abscess involving the cerebellum
    • Septo-optic dysplasia
      –Optic nerve hypoplasia, associated with other midline brain defects
      –Endocrine abnormalities are common (diabetes insipidus, hypoglycemia, hypopituitarism, failure to thrive)
  • Toxicity
    –Medications include barbiturates, hydantoin, antihistamines, and salicylates
    –Lead toxicity
    –Alcohol intoxication may involve vestibular disturbances including vertigo, nystagmus
    • Opsoclonus
      –Not true nystagmus
      –Eye movements that may be mistaken for nystagmus (e.g., opsoclonus-myoclonus disorder)

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Ocular deviation: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain tumor

The nature of ocular deviation depends on the site and extent of the tumor. Associated signs and symptoms include headaches that are most severe in the morning, behavioral changes, memory loss, dizziness, confusion, vision loss, motor and sensory dysfunction, aphasia and, possibly, signs of hormonal imbalance. The patient’s LOC may slowly deteriorate from lethargy to coma. Late signs include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and decorticate posture.

Cavernous sinus thrombosis

With cavernous sinus thrombosis, ocular deviation may be accompanied by diplopia, photophobia, exophthalmos, orbital and eyelid edema, corneal haziness, diminished or absent pupillary reflexes, and impaired visual acuity. Other features include a high fever, a headache, malaise, nausea and vomiting, seizures, and tachycardia. Retinal hemorrhage and papilledema are late signs.

Diabetes mellitus

A leading cause of isolated third cranial nerve palsy, especially in the middle-aged patient with long-standing mild diabetes, diabetes mellitus may cause ocular deviation and ptosis. Typically, the patient also complains of the sudden onset of diplopia and pain.

Encephalitis

Encephalitis causes ocular deviation and diplopia in some cases. Typically, it begins abruptly with a fever, a headache, and vomiting, followed by signs of meningeal irritation (for example, nuchal rigidity) and neuronal damage (for example, seizures, aphasia, ataxia, hemiparesis, cranial nerve palsies, and photophobia). The patient’s LOC may rapidly deteriorate from lethargy to coma within 24 to 48 hours after onset.

Head trauma

The nature of ocular deviation depends on the site and extent of head trauma. The patient may have visible soft-tissue injury, bony deformity, facial edema, and clear or bloody otorrhea or rhinorrhea. Besides these obvious signs of trauma, he may also develop blurred vision, diplopia, nystagmus, behavioral changes, a headache, motor and sensory dysfunction, and a decreased LOC that may progress to coma. Signs of increased intracranial pressure — such as bradycardia, increased systolic pressure, and widening pulse pressure — may also occur.

Orbital blowout fracture

In orbital blowout fracture, the inferior rectus muscle may become entrapped, resulting in limited extraocular movement and ocular deviation. Typically, the patient’s upward gaze is absent; other directions of gaze may be affected if edema is dramatic. The globe may also be displaced downward and inward. Associated signs and symptoms include pain, diplopia, nausea, periorbital edema, and ecchymosis.

Orbital tumor

Ocular deviation occurs as the tumor gradually enlarges. Associated findings include proptosis, diplopia and, possibly, blurred vision.

Stroke

Stroke, a life-threatening disorder, may cause ocular deviation, depending on the site and extent of the stroke. Accompanying features are also variable and include an altered LOC, contralateral hemiplegia and sensory loss, dysarthria, dysphagia, homonymous hemianopsia, blurred vision, and diplopia. In addition, the patient may develop urine retention or incontinence or both, constipation, behavioral changes, a headache, vomiting, and seizures.

Thyrotoxicosis

Thyrotoxicosis may produce exophthalmos — proptotic or protruding eyes — which, in turn, causes limited extraocular movement and ocular deviation. Usually, the patient’s upward gaze weakens first, followed by diplopia. Other features are lid retraction, a wide-eyed staring gaze, excessive tearing, edematous eyelids and, sometimes, an inability to close the eyes. Cardinal features of thyrotoxicosis include tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance, and an atrial or a ventricular gallop.

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Nystagmus: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain tumor

An insidious onset of jerk nystagmus may occur with tumors of the brain stem and cerebellum. Associated characteristics include deafness, dysphagia, nausea and vomiting, vertigo, and ataxia. Brain stem compression by the tumor may cause signs of increased ICP, such as an altered LOC, bradycardia, a widening pulse pressure, and an elevated systolic blood pressure.

Encephalitis

With encephalitis, jerk nystagmus is typically accompanied by an altered LOC ranging from lethargy to coma. Usually, it’s preceded by sudden onset of a fever, a headache, and vomiting. Among other features are nuchal rigidity, seizures, aphasia, ataxia, photophobia, and cranial nerve palsies, such as dysphagia and ptosis.

Head trauma

Brain stem injury may cause jerk nystagmus, which is usually horizontal. The patient may also display pupillary changes, an altered respiratory pattern, coma, and decerebrate posture.

Labyrinthitis (acute)

Acute labyrinthitis is an inner ear inflammation that causes a sudden onset of jerk nystagmus, accompanied by dizziness, vertigo, tinnitus, nausea, and vomiting. The fast component of the nystagmus is toward the unaffected ear. Gradual sensorineural hearing loss may also occur.

Ménière’s disease

Ménière’s disease is an inner ear disorder that’s characterized by acute attacks of jerk nystagmus, severe nausea and vomiting, dizziness, vertigo, progressive hearing loss, tinnitus, and diaphoresis. Typically, the direction of jerk nystagmus varies from one attack to the next. Attacks may last from 10 minutes to several hours.

Stroke

A stroke involving the posterior inferior cerebellar artery may cause sudden horizontal or vertical jerk nystagmus that may be gaze dependent. Other findings include dysphagia, dysarthria, loss of pain and temperature sensation on the ipsilateral face and contralateral trunk and limbs, ipsilateral Horner’s syndrome (unilateral ptosis, pupillary constriction, and facial anhidrosis), and cerebellar signs, such as ataxia and vertigo. Signs of increased ICP (such as an altered LOC, bradycardia, a widening pulse pressure, and an elevated systolic pressure) may also occur.

Other causes

Drugs and alcohol

Jerk nystagmus may result from barbiturate, phenytoin, or carbamazepine toxicity or from alcohol intoxication.

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Ocular deviation: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Brain tumor

The nature of ocular deviation depends on the site and extent of the tumor. Associated signs and symptoms include headaches that are most severe in the morning, behavioral changes, memory loss, dizziness, confusion, vision loss, motor and sensory dysfunction, aphasia and, possibly, signs of hormonal imbalance. The patient’s LOC may slowly deteriorate from lethargy to coma. Late signs include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and decorticate posture.

Cavernous sinus thrombosis

In this disorder, ocular deviation may be accompanied by diplopia, photophobia, exophthalmos, orbital and eyelid edema, corneal haziness, diminished or absent pupillary reflexes, and impaired visual acuity. Other features include high fever, headache, malaise, nausea and vomiting, seizures, and tachycardia. Retinal hemorrhages and papilledema are late signs.

Cerebral aneurysm

When an aneurysm near the internal carotid artery compresses the oculomotor nerve, it may produce features that resemble third cranial nerve palsy. Typically, ocular deviation and diplopia are the presenting signs. Other cardinal findings include ptosis, a dilated pupil on the affected side, and a severe, unilateral headache, usually in the frontal area. Rupture of the aneurysm abruptly intensifies the pain, which may be accompanied by nausea and vomiting. Bleeding from the site causes meningeal irritation, resulting in nuchal rigidity, back and leg pain, fever, irritability, occasional seizures, and blurred vision. Other signs and symptoms associated with intracranial bleeding include hemiparesis, dysphagia, and visual defects.

Diabetes mellitus

A leading cause of isolated third cranial nerve palsy, especially in the middle-age patient with long-standing mild diabetes, this disorder may cause ocular deviation and ptosis. Typically, the patient also complains of sudden onset of diplopia and pain.

Encephalitis

This infection causes ocular deviation and diplopia in some patients. Typically, it begins abruptly with fever, headache, and vomiting, followed by signs of meningeal irritation (for example, nuchal rigidity) and of neuronal damage (for example, seizures, aphasia, ataxia, hemiparesis, cranial nerve palsies, and photophobia). The patient’s LOC may rapidly deteriorate from lethargy to coma within 24 to 48 hours after onset.

Head trauma

The nature of ocular deviation depends on the site and extent of head trauma. The patient may have visible soft-tissue injury, bony deformity, facial edema, and clear or bloody otorrhea or rhinorrhea. Besides these obvious signs of trauma, he may also develop blurred vision, diplopia, nystagmus, behavioral changes, headache, motor and sensory dysfunction, and a decreased LOC that may progress to coma. Signs of increased intracranial pressure—such as bradycardia, increased systolic pressure, and widening pulse pressure—may also occur.

Multiple sclerosis

Ocular deviation may be an early sign of this disorder. Accompanying it are diplopia, blurred vision, and sensory dysfunction, such as paresthesia. Other signs and symptoms include nystagmus, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, and emotional instability. In addition, the patient may experience urinary frequency, urgency, and incontinence.

Myasthenia gravis

Ocular deviation may accompany the more common presenting signs of diplopia and ptosis. This disorder may affect only the eye muscles, or it may progress to other muscle groups, causing altered facial expression, difficulty chewing, dysphagia, weakened voice, and impaired fine hand movements. Signs of respiratory distress reflect weakness of the diaphragm and other respiratory muscles.

Ophthalmoplegic migraine

Most common in young adults, this disorder produces ocular deviation and diplopia that persist for days after the pain subsides. Associated signs and symptoms include unilateral headache, possibly with ptosis on the same side; temporary hemiplegia; and sensory deficits. Irritability, depression, or slight confusion may also occur.

Orbital blowout fracture

In this fracture, the inferior rectus muscle may become entrapped, resulting in limited extraocular movement and ocular deviation. Typically, the patient’s upward gaze is absent; other directions of gaze may be affected if edema is dramatic. The globe may also be displaced downward and inward. Associated signs and symptoms include pain, diplopia, nausea, periorbital edema, and ecchymosis.

Orbital cellulitis

This disorder may cause sudden onset of ocular deviation and diplopia. Other signs and symptoms include unilateral eyelid edema and erythema, hyperemia, chemosis, and extreme orbital pain. Purulent discharge makes eyelashes matted and sticky. Proptosis is a late sign.

Orbital tumor

Ocular deviation occurs as the tumor gradually enlarges. Associated findings include proptosis, diplopia and, possibly, blurred vision.

Stroke

This life-threatening disorder may cause ocular deviation, depending on the site and extent of the stroke. Accompanying features are also variable and include altered LOC, contralateral hemiplegia and sensory loss, dysarthria, dysphagia, homonymous hemianopsia, blurred vision, and diplopia. In addition, the patient may develop urine retention or incontinence or both, constipation, behavioral changes, headache, vomiting, and seizures.

Thyrotoxicosis

This disorder may produce exophthalmos—proptotic or protruding eyes—which, in turn, causes limited extraocular movement and ocular deviation. Usually, the patient’s upward gaze weakens first, followed by diplopia. Other features are lid retraction, a wide-eyed staring gaze, excessive tearing, edematous eyelids and, sometimes, inability to close the eyes. Cardinal features of thyrotoxicosis include tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance, and an atrial or ventricular gallop.

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Nystagmus: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Brain tumor

Insidious onset of jerk nystagmus may occur with tumors of the brain stem and cerebellum. Associated characteristics include deafness, dysphagia, nausea and vomiting, vertigo, and ataxia. Brain stem compression by the tumor may cause signs of increased ICP, such as altered LOC, bradycardia, widening pulse pressure, and elevated systolic blood pressure.

Encephalitis

With this disorder, jerk nystagmus is typically accompanied by altered LOC ranging from lethargy to coma. Usually, it’s preceded by sudden onset of fever, headache, and vomiting. Among other features are nuchal rigidity, seizures, aphasia, ataxia, photophobia, and cranial nerve palsies, such as dysphagia and ptosis.

Head trauma

Brain stem injury may cause jerk nystagmus, which is usually horizontal. The patient may also display pupillary changes, altered respiratory pattern, coma, and decerebrate posture.

Labyrinthitis (acute)

This inner ear inflammation causes sudden onset of jerk nystagmus, accompanied by dizziness, vertigo, tinnitus, nausea, and vomiting. The fast component of the nystagmus is toward the unaffected ear. Gradual sensorineural hearing loss may also occur.

Ménière’s disease

This inner ear disorder is characterized by acute attacks of jerk nystagmus, severe nausea and vomiting, dizziness, vertigo, progressive hearing loss, tinnitus, and diaphoresis. Typically, the direction of jerk nystagmus varies from one attack to the next. Attacks may last from 10 minutes to several hours.

Multiple sclerosis

With this disorder, jerk or pendular nystagmus may occur intermittently. Usually, it’s preceded by diplopia, blurred vision, and paresthesia. Related signs and symptoms may include muscle weakness or paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, and emotional instability. The patient may also develop constipation, as well as urinary frequency, urgency, and incontinence.

Stroke

A stroke involving the posterior inferior cerebellar artery may cause sudden horizontal or vertical jerk nystagmus that may be gaze dependent. Other findings include dysphagia, dysarthria, loss of pain and temperature sensation on the ipsilateral face and contralateral trunk and limbs, ipsilateral Horner’s syndrome (unilateral ptosis, pupillary constriction, and facial anhidrosis), and cerebellar signs, such as ataxia and vertigo. Signs of increased intracranial pressure (such as altered LOC, bradycardia, widening pulse pressure, and elevated systolic pressure) may also occur.

Other causes

Drugs and alcohol

Jerk nystagmus may result from barbiturate, phenytoin, or carbamazepine toxicity, or from alcohol intoxication.

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Eye pain [Ophthalmalgia]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acute angle-closure glaucoma

Blurred vision and sudden excruciating pain in and around the eye characterize this disorder; the pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Astigmatism

Uncorrected astigmatism commonly causes headaches and eye fatigue, aching, and redness. This disorder occurs in both older and younger people.

Blepharitis

Burning pain in both eyelids is accompanied by conjunctival injection and an itching, sticky discharge. Related findings include a foreign-body sensation, eyelid ulcerations, and loss of eyelashes.

Burns

In chemical burns, sudden severe eye pain may occur with erythema and blistering of the face and eyelids, photophobia, miosis, conjunctival injection, blurring, and inability to keep the eyelids open. In ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion

A chalazion causes localized tenderness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis

Some degree of eye pain and excessive tearing occur in four types of conjunctivitis. Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge.

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it typically produces burning, a foreign-body sensation, a purulent discharge, and conjunctival injection.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes; a foreign-body sensation; visible conjunctival follicles; and eyelid edema.

Corneal abrasions

This type of injury typically produces a foreign-body sensation, excessive tearing, photophobia, and conjunctival injection.

Corneal erosion (recurrent)

In this disorder, severe pain occurs on waking and continues throughout the day. Accompanying the pain are conjunctival injection and photophobia.

Corneal ulcers

Both bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea; unilateral pupil constriction; and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryoadenitis

Temporal pain may affect both eyes in this disorder. Associated findings include exophthalmos, conjunctival injection, severe eyelid erythema and edema, and a purulent eye discharge.

Dacryocystitis

Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling around the lacrimal punctum.

Episcleritis

Deep eye pain occurs as tissues over the sclera become inflamed. Related effects include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.

Erythema multiforme major

This disorder commonly produces severe eye pain, entropion, trichiasis, purulent conjunctivitis, photophobia, and decreased tear formation.

Foreign bodies in the cornea and conjunctiva

Sudden severe pain is common in this condition, but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Glaucoma

Open-angle glaucoma may cause mild aching in the eyes as well as loss of peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Acute angle-closure glaucoma may cause severe pain and pressure over the eye, blurred vision, halo vision, decreased visual acuity, and nausea and vomiting.

Herpes zoster ophthalmicus

Eye pain occurs with severe unilateral facial pain, usually several days before vesicles erupt. Other signs include red, swollen eyelids; excessive tearing; a serous eye discharge; conjunctival injection; and a white, cloudy cornea.

Hordeolum (stye)

This lesion usually produces localized eye pain that increases as the stye grows. Eyelid erythema and edema are also common.

Hyphema

Occurring after eye injury or surgery, hyphema accompanies sudden pain in and around the eye. Orbital and eyelid edema, conjunctival injection, and visual impairment may also occur.

Interstitial keratitis

Associated with congenital syphilis, this corneal inflammation produces eye pain with photophobia, blurred vision, prominent conjunctival injection, and grayish pink corneas.

Iritis (acute)

Moderate to severe eye pain occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.

Keratoconjunctivitis sicca

This condition—known as dry eye syndrome—causes chronic burning pain in both eyes, itching, a foreign-body sensation, photophobia, dramatic conjunctival injection, and difficulty moving the eyelids. A copious mucoid discharge and inadequate tearing are typical.

Lacrimal gland tumor

This neoplastic lesion usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.

Migraine headache

Migraines can produce head pain so severe that the eyes also ache. Nausea, vomiting, blurred vision, and light and noise sensitivity may also occur.

Ocular laceration and intraocular foreign bodies

Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic cellulitis

This disorder causes dull, aching pain in the affected eye, some degree of exophthalmos, eyelid edema and erythema, a purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity and fever.

Optic neuritis

In this disorder, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Orbital floor fracture

Sometimes called a blowout fracture, this injury causes eye pain, dramatic eyelid edema and, possibly, enophthalmos and diplopia.

Orbital pseudotumor

This disorder causes deep, boring eye pain and diplopia in about 50% of patients. However, prominent exophthalmos and lateral ocular deviation are more characteristic. Eyelid edema and limited extraocular movement may also occur.

Pemphigus

In this disorder, bilateral eye pain and irritation may be accompanied by blurred vision and a thick discharge. Blisters may develop on the conjunctiva alone or may extend to the nasal, oral, and vulvar mucous membranes as well as the skin.

Scleritis

This inflammation produces severe eye pain and tenderness, conjunctival injection, bluish purple sclera and, possibly, photophobia and excessive tearing.

Sclerokeratitis

Inflammation of the sclera and cornea causes pain, burning, irritation, and photophobia.

Subdural hematoma

Following head trauma, a subdural hematoma commonly causes severe eye ache and headache. Related neurologic signs depend on the hematoma’s location and size.

Trachoma

Along with pain in the affected eye, trachoma causes excessive tearing, photophobia, an eye discharge, eyelid edema and erythema, and visible conjunctival follicles.

Uveitis

Anterior uveitis causes sudden severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.

Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Treatments

Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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Eye Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Conjunctivitis

❑ Corneal abrasion

❑ Foreign body

❑ Sinusitis

❑ Migraine

❑ Acute glaucoma

❑ Orbital cellulitis

❑ Zoster prodrome

❑ Orbital fracture

❑ Keratitis

❑ Scleritis

❑ Iritis

❑ Optic neuritis

❑ Temporal arteritis

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Diplopia/Nystagmus: Differential Overview
(Field Guide to Bedside Diagnosis)

Diplopia

❑ Alcohol

❑ Diabetes

❑ Brainstem ischemia/lesion

❑ Grave disease

❑ Multiple sclerosis

❑ Ophthalmoplegic migraine

❑ Myasthenia gravis

❑ Wernicke encephalopathy

❑ Zygoma fracture

❑ Basilar meningitis

❑ Posterior communicating artery aneurysm

❑ Cavernous sinus thrombosis

❑ Syphilis

❑ Guillain-Barré variant

❑ Botulism

Nystagmus

❑ Labyrinthitis

❑ Multiple sclerosis

❑ Oculogyric crisis

❑ Cerebellar lesion

❑ Brainstem lesion

❑ Frontal lesion

❑ Occipital lesion

❑ Dorsal midbrain lesion

❑ Heavy metal intoxication

❑ Congenital

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Involuntary Weight Loss: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Diabetes

❑ Depression

❑ Inadequate intake

❑ Drugs

❑ Hyperthyroidism

❑ Occult cancer

❑ Low cardiac output

❑ Anorexia nervosa

❑ Malabsorption

❑ Chronic infection

❑ Adrenal insufficiency

❑ Emphysema

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Eye pain: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

See Eye pain: causes and associated findings, page 142.

Acute angle-closure glaucoma

Blurred vision and sudden, excruciating pain in and around the eye characterize acute angle-closure glaucoma; the pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Astigmatism

Uncorrected astigmatism commonly causes headache and eye fatigue, aching, and redness. This disorder occurs in both older and younger people.

Blepharitis

Burning pain in both eyelids is accompanied by itching, sticky discharge, and conjunctival injection. Related findings include foreign-body sensation, lid ulcerations, and loss of eyelashes.

Burns

With chemical burns, sudden and severe eye pain may occur with erythema and blistering of the face and lids, photophobia, miosis, conjunctival injection, blurring, and inability to keep the eyelids open. (See Eye irrigation for chemical burns, page 143.) With ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion

A chalazion causes localized tenderness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis

Some degree of eye pain and excessive tearing occurs with four types of conjunctivitis. Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge.

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it produces burning and a foreign-body sensation. A purulent discharge and conjunctival injection are also typical.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Even without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes, foreign-body sensation, visible conjunctival follicles, and eyelid edema.

Corneal abrasions

With corneal abrasions, eye pain is characterized by a foreign-body sensation. Excessive tearing, photophobia, and conjunctival injection are also common.

Corneal erosion (recurrent)

Severe pain occurs on waking and continues throughout the day. Accompanying the pain are conjunctival injection and photophobia.

Corneal ulcers

Both bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea, unilateral pupil constriction, and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryoadenitis

Temporal pain may affect both eyes in dacryoadenitis. Associated findings include exophthalmos, conjunctival injection, severe eyelid erythema and edema, and a purulent eye discharge.

Dacryocystitis

Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include profuse tearing, a purulent discharge, eyelid erythema, and swelling in the lacrimal punctum area.

Episcleritis

Deep eye pain occurs as tissues over sclera become inflamed. Related effects include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.

Erythema multiforme major

Erythema multiforme major commonly produces severe eye pain, entropion, trichiasis, purulent conjunctivitis, photophobia, and decreased tear formation.

Foreign bodies in the cornea and conjunctiva

Sudden severe pain is common but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Glaucoma

Open-angle glaucoma may cause mild aching in the eyes as well as loss of peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Angle-closure glaucoma may cause pain and pressure over the eye, blurred vision, halo vision, decreased visual acuity, and nausea and vomiting.

Herpes zoster ophthalmicus

Eye pain occurs with severe unilateral facial pain, usually several days before vesicles erupt. Other signs include red, swollen eyelids; excessive tearing; a serous eye discharge; conjunctival injection; and a white, cloudy cornea.

Hordeolum (stye)

Hordeolum is a lesion that usually produces localized eye pain that increases as the stye grows. Eyelid erythema and edema are also common.

Hyphema

Occurring after eye injury or surgery, hyphema accompanies sudden pain in and around the eye. Orbital and lid edema, conjunctival injection, and visual impairment may occur.

Interstitial keratitis

Associated with congenital syphilis, interstitial keratitis produces eye pain with photophobia, blurred vision, prominent conjunctival injection, and grayish pink corneas.

Iritis (acute)

Moderate to severe eye pain occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.

Keratoconjunctivitis sicca

Keratoconjunctivitis sicca — known as dry eye syndrome — causes chronic burning pain in both eyes, itching, a foreign-body sensation, photophobia, dramatic conjunctival injection, and difficulty moving the eyelids. Excessive mucoid discharge and inadequate tearing are typical.

Lacrimal gland tumor

Lacrimal gland tumor is a neoplastic lesion that usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.

Migraine headache

Migraines can produce pain so severe that the eyes also ache. Additionally, nausea, vomiting, blurred vision, and light and noise sensitivity may occur.

Ocular laceration and intraocular foreign bodies

Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic cellulitis

Optic cellulitis causes dull, aching pain in the affected eye, some degree of exophthalmos, eyelid edema and erythema, purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity and fever.

Optic neuritis

With optic neuritis, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Orbital floor fracture

Sometimes called a blowout fracture, orbital floor fracture causes eye pain, dramatic eyelid edema and, possibly, enophthalmos and diplopia.

Orbital pseudotumor

Orbital pseudotumor causes deep, boring eye pain and diplopia in about 50% of all patients. However, prominent exophthalmos and lateral ocular deviation are more characteristic. Eyelid edema and restricted extraocular movement may also occur.

Pemphigus

With pemphigus, bilateral eye pain and irritation may be accompanied by blurred vision and a thick discharge. Blisters may develop on the conjunctiva alone or may extend to the nasal, oral, and vulvar mucous membranes as well as the skin.

Scleritis

Scleritis is a inflammation that produces severe eye pain and tenderness, along with conjunctival injection, bluish purple sclera and, possibly, photophobia, loss of vision, and excessive tearing.

Sclerokeratitis

Inflammation of the sclera and cornea causes pain, burning, irritation, and photophobia.

Subdural hematoma

After head trauma, a subdural hematoma commonly causes severe eye ache and headache. Related neurologic signs depend on the hematoma’s location and size.

Trachoma

Along with pain in the affected eye, trachoma causes excessive tearing, photophobia, eye discharge, eyelid edema and redness, and visible conjunctival follicles.

Uveitis

Anterior uveitis causes sudden onset of severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.

Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Medical treatments

Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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Ocular deviation: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Brain tumor

The nature of ocular deviation depends on the site and extent of the tumor. Associated signs and symptoms include headaches that are most severe in the morning, behavioral changes, memory loss, dizziness, confusion, vision loss, motor and sensory dysfunction, aphasia and, possibly, signs of hormonal imbalance. The patient’s LOC may slowly deteriorate from lethargy to coma. Late signs include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and decorticate posture.

Cavernous sinus thrombosis

In cavernous sinus thrombosis, ocular deviation may be accompanied by diplopia, photophobia, exophthalmos, orbital and eyelid edema, corneal haziness, diminished or absent pupillary reflexes, and impaired visual acuity. Other features include high fever, headache, malaise, nausea and vomiting, seizures, and tachycardia. Retinal hemorrhage and papilledema are late signs.

Cerebral aneurysm

When an aneurysm near the internal carotid artery compresses the oculomotor nerve, it may produce features that resemble third cranial nerve palsy. Typically, ocular deviation and diplopia are the presenting signs. Other cardinal findings include ptosis, a dilated pupil on the affected side, and a severe, unilateral headache, usually in the frontal area. Rupture of the aneurysm abruptly intensifies the pain, which may be accompanied by nausea and vomiting. Bleeding from the site causes meningeal irritation, resulting in nuchal rigidity, back and leg pain, fever, irritability, occasional seizures, and blurred vision. Other signs and symptoms associated with intracranial bleeding include hemiparesis, dysphagia, and visual defects.

Diabetes mellitus

A leading cause of isolated third cranial nerve palsy, especially in the middle-age patient with long-standing mild diabetes, diabetes mellitus may cause ocular deviation and ptosis. Typically, the patient also complains of a sudden onset of diplopia and pain.

Encephalitis

Encephalitis may cause ocular deviation and diplopia. Typically, it begins abruptly with fever, headache, and vomiting, followed by signs of meningeal irritation (for example, nuchal rigidity) and of neuronal damage (for example, seizures, aphasia, ataxia, hemiparesis, cranial nerve palsies, and photophobia). The patient’s LOC may rapidly deteriorate from lethargy to coma.

Head trauma

The nature of ocular deviation depends on the site and extent of head trauma. The patient may have visible soft-tissue injury, bony deformity, facial edema, and clear or bloody otorrhea or rhinorrhea. Besides these obvious signs of trauma, he may also develop blurred vision, diplopia, nystagmus, behavioral changes, headache, motor and sensory dysfunction, and a decreased LOC that may progress to coma. Signs of increased intracranial pressure — such as bradycardia, increased systolic pressure, and widening pulse pressure — may also occur.

Multiple sclerosis (MS)

Ocular deviation may be an early sign of MS. Accompanying it are diplopia, blurred vision, and sensory dysfunction such as paresthesia. Other signs and symptoms include nystagmus, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, and emotional instability. In addition, the patient may experience urinary frequency, urgency, and incontinence.

Myasthenia gravis

Ocular deviation may accompany the more common presenting signs of diplopia and ptosis. Myasthenia gravis may affect only the eye muscles, or it may progress to other muscle groups, causing altered facial expression, difficulty chewing, dysphagia, weakened voice, and impaired fine hand movements. Signs of respiratory distress reflect weakness of the diaphragm and other respiratory muscles.

Ophthalmoplegic migraine

Most common in young adults, ophthalmoplegic migraine produces ocular deviation and diplopia that persist for days after the pain subsides. Associated signs and symptoms include unilateral headache, possibly with ptosis on the same side; temporary hemiplegia; and sensory deficits. Irritability, depression, or slight confusion may also occur.

Orbital blowout fracture

In orbital blowout fracture, the inferior rectus muscle may become entrapped, resulting in limited extraocular movement and ocular deviation. Typically, the patient’s upward gaze is absent; other directions of gaze may be affected if edema is dramatic. The globe may also be displaced downward and inward. Associated signs and symptoms include pain, diplopia, nausea, periorbital edema, and ecchymosis.

Orbital cellulitis

Orbital cellulitis may cause a sudden onset of ocular deviation and diplopia. Other signs and symptoms include unilateral eyelid edema and erythema, hyperemia, chemosis, and extreme orbital pain. Purulent discharge makes eyelashes matted and sticky. Proptosis is a late sign.

Orbital tumor

Ocular deviation occurs as the tumor gradually enlarges. Associated findings include proptosis, diplopia and, possibly, blurred vision.

Stroke

Stroke is a life-threatening disorder that may cause ocular deviation, depending on the site and extent of the stroke. Accompanying features are also variable and include an altered LOC, contralateral hemiplegia and sensory loss, dysarthria, dysphagia, homonymous hemianopsia, blurred vision, and diplopia. In addition, the patient may develop urine retention or incontinence or both, constipation, behavioral changes, headache, vomiting, and seizures.

Thyrotoxicosis

The patient with thyrotoxicosis may also experience exophthalmos — proptotic or protruding eyes — which, in turn, causes limited extraocular movement and ocular deviation. Usually, the patient’s upward gaze weakens first, followed by diplopia. Other features are lid retraction, a wide-eyed staring gaze, excessive tearing, edematous eyelids and, sometimes, an inability to close the eyes. Cardinal features of thyrotoxicosis include tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance, and an atrial or ventricular gallop.

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Eye pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Blepharitis

With blepharitis, burning pain in both eyelids is accompanied by itching, sticky discharge, and conjunctival injection. Related findings include foreign-body sensation, lid ulcerations, and loss of eyelashes.

Burns

With chemical burns, sudden and severe eye pain may occur with erythema and blistering of the face and lids, photophobia, miosis, conjunctival injection, blurring, and inability to keep the eyelids open. With ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion

A chalazion causes localized pain, tenderness, redness, and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis

Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge.

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it produces burning and a foreign-body sensation. A purulent discharge and conjunctival injection are also typical.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Even without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes, foreign-body sensation, visible conjunctival follicles, and eyelid edema.

Corneal abrasions

With corneal abrasions, eye pain is characterized by a foreign-body sensation. Excessive tearing, photophobia, and conjunctival injection are also common. The patient commonly reports feeling that “something is in” the eye.

Corneal erosion (recurrent)

With recurrent corneal erosion, severe pain occurs on waking and continues throughout the day. Conjunctival injection and photophobia also occur.

Corneal ulcers

Both bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea, unilateral pupil constriction, and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryocystitis

Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling in the lacrimal punctum area.

Foreign body in the cornea or conjunctiva

Sudden severe pain is common but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Glaucoma

Open-angle glaucoma may cause mild aching in the eyes as well as loss of peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Angle-closure glaucoma is characterized by blurred vision and sudden, excruciating pain in and around the eye. The pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Herpes zoster ophthalmicus

With herpes zoster ophthalmicus, eye pain occurs with severe unilateral facial pain, usually days before vesicles erupt. Other signs include red, swollen eyelids; excessive tearing; a serous eye discharge; conjunctival injection; and a white, cloudy cornea.

Hordeolum

A hordeolum (stye) usually produces localized eye pain, burning, and discomfort that increases as the stye grows. Eyelid erythema and edema are also common.

Hyphema

Occurring after eye injury or surgery, hyphema accompanies sudden pain in and around the eye. Orbital and lid edema, conjunctival injection, and visual impairment may occur. The patient may report nausea.

Keratoconjunctivitis sicca

Keratoconjunctivitis sicca, also known as dry eye syndrome, causes chronic burning pain in both eyes, itching, a foreign-body sensation, photophobia, dramatic conjunctival injection, and difficulty moving the eyelids. Excessive mucoid discharge and inadequate tearing are typical.

Lacrimal gland tumor

Lacrimal gland tumor is a neoplastic lesion that usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos. The patient may also have ptosis and eye deviation.

Ocular laceration and intraocular foreign bodies

Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic cellulitis

Optic cellulitis causes dull, aching pain in the affected eye, some degree of exophthalmos, eyelid edema and erythema, purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity and fever.

Optic neuritis

With optic neuritis, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Orbital floor fracture

Sometimes called a blowout fracture, orbital floor fracture causes eye pain, dramatic eyelid edema and, possibly, enophthalmos and diplopia. The patient may report recent eye trauma and reduced vision. Ecchymosis and ptosis may be visible.

Orbital pseudotumor

An orbital pseudotumor causes deep, boring eye pain and diplopia in about 50% of patients. However, prominent exophthalmos and lateral ocular deviation are more characteristic. Eyelid edema and restricted extraocular movement may also occur.

Uveitis

Anterior uveitis causes sudden onset of severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil. Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape. Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity (the patient usually can perceive only light).

Other causes

Treatments

Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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Ocular deviation: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Brain tumor

The nature of ocular deviation depends on the site and extent of the tumor. Associated signs and symptoms include headaches that are most severe in the morning, behavioral changes, memory loss, dizziness, confusion, vision loss, motor and sensory dysfunction, aphasia and, possibly, signs of hormonal imbalance. The patient’s LOC may slowly deteriorate from lethargy to coma. Late signs include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and decorticate posture.

Cerebral aneurysm

When an aneurysm near the internal carotid artery compresses the oculomotor nerve, it may produce features that resemble third cranial nerve palsy. Typically, ocular deviation and diplopia are the presenting signs. Other cardinal findings include ptosis, a dilated pupil on the affected side, and a severe, unilateral headache, usually in the frontal area. Rupture of the aneurysm abruptly intensifies the pain, which may be accompanied by nausea and vomiting. Bleeding from the site causes meningeal irritation, resulting in nuchal rigidity, back and leg pain, fever, irritability, occasional seizures, and blurred vision. Other signs and symptoms associated with intracranial bleeding include hemiparesis, dysphagia, and visual defects.

Diabetes mellitus

A leading cause of isolated third cranial nerve palsy, especially in the middle-age patient with long-standing mild diabetes, diabetes mellitus may cause ocular deviation and ptosis. Typically, the patient also complains of sudden onset of diplopia and pain.

Encephalitis

Encephalitis causes ocular deviation and diplopia in some patients. Typically, it begins abruptly with fever, headache, and vomiting, followed by signs of meningeal irritation (for example, nuchal rigidity) and of neuronal damage (for example, seizures, aphasia, ataxia, hemiparesis, cranial nerve palsies, and photophobia). The patient’s LOC may rapidly deteriorate from lethargy to coma within 24 to 48 hours after onset.

Head trauma

The nature of ocular deviation depends on the site and extent of head trauma. The patient may have visible soft-tissue injury, bony deformity, facial edema, and clear or bloody otorrhea or rhinorrhea. Besides these obvious signs of trauma, he may also develop blurred vision, diplopia, nystagmus, behavioral changes, headache, motor and sensory dysfunction, and a decreased LOC that may progress to coma. Signs of increased intracranial pressure — such as bradycardia, increased systolic pressure, and widening pulse pressure — may also occur.

Multiple sclerosis

Ocular deviation may be an early sign of multiple sclerosis. Accompanying it are diplopia, blurred vision, and sensory dysfunction such as paresthesia. Other signs and symptoms include nystagmus, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, and emotional instability. In addition, the patient may experience urinary frequency, urgency, and incontinence.

Myasthenia gravis

With myasthenia gravis, ocular deviation may accompany the more common presenting signs of diplopia and ptosis. This disorder may affect only the eye muscles, or it may progress to other muscle groups, causing altered facial expression, difficulty chewing, dysphagia, weakened voice, and impaired fine hand movements. Signs of respiratory distress reflect weakness of the diaphragm and other respiratory muscles.

Ophthalmoplegic migraine

Most common in young adults, an ophthalmoplegic migraine produces ocular deviation and diplopia that persist for days after the pain subsides. Associated signs and symptoms include unilateral headache, possibly with ptosis on the same side; temporary hemiplegia; and sensory deficits. Irritability, depression, or slight confusion may also occur.

Orbital blowout fracture

In an orbital blowout fracture, the inferior rectus muscle may become entrapped, resulting in limited extraocular movement and ocular deviation. Typically, the patient’s upward gaze is absent; other directions of gaze may be affected if edema is dramatic. The globe may also be displaced downward and inward. Associated signs and symptoms include pain, diplopia, nausea, periorbital edema, and ecchymosis.

Orbital tumor

Ocular deviation occurs as the tumor gradually enlarges. Associated findings include proptosis, diplopia and, possibly, blurred vision. The eyelid may also appear edematous.

Stroke

Stroke is a life-threatening disorder that may cause ocular deviation, depending on the site and extent of the stroke. Accompanying features of a stroke are also variable and include altered LOC, contralateral hemiplegia and sensory loss, dysarthria, dysphagia, homonymous hemianopsia, blurred vision, and diplopia. In addition, the patient may develop urine retention or incontinence or both, constipation, behavioral changes, headache, vomiting, and seizures.

Thyrotoxicosis

Thyrotoxicosis may produce exophthalmos — protruding eyes — which, in turn, causes limited extraocular movement and ocular deviation. Usually, the patient’s upward gaze weakens first, followed by diplopia. Other features are lid retraction, a wide-eyed staring gaze, excessive tearing, edematous eyelids and, sometimes, inability to close the eyes. Cardinal features of thyrotoxicosis include tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance, and an atrial or ventricular gallop.

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Nystagmus: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Encephalitis

With encephalitis, jerk nystagmus is typically accompanied by altered LOC ranging from lethargy to coma. Usually, it’s preceded by sudden onset of fever, headache, and vomiting. Among other features are nuchal rigidity, seizures, aphasia, ataxia, photophobia, and cranial nerve palsies, such as dysphagia and ptosis.

Head trauma

Brain stem injury may cause jerk nystagmus, which is usually horizontal. The patient may also display pupillary changes, altered respiratory pattern, coma, and decerebrate posture.

Labyrinthitis (acute)

Acute labyrinthitis is inner ear inflammation that causes sudden onset of jerk nystagmus, accompanied by dizziness, vertigo, tinnitus, nausea, and vomiting. The fast component of the nystagmus is toward the unaffected ear. Gradual sensorineural hearing loss may also occur.

Ménière’s disease

Ménière’s disease, an inner ear disorder, is characterized by acute attacks of jerk nystagmus, severe nausea and vomiting, dizziness, vertigo, progressive hearing loss, tinnitus, and diaphoresis. Typically, the direction of jerk nystagmus varies from one attack to the next. Attacks may last from 10 minutes to several hours.

Multiple sclerosis

With multiple sclerosis, jerk or pendular nystagmus may occur intermittently. Usually, it’s preceded by diplopia, blurred vision, and paresthesia. Related signs and symptoms may include muscle weakness or paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, and emotional instability. The patient may also develop constipation, as well as urinary frequency, urgency, and incontinence.

Stroke

A stroke involving the posterior inferior cerebellar artery may cause sudden horizontal or vertical jerk nystagmus that may be gaze dependent. Other findings include dysphagia, dysarthria, loss of pain and temperature sensation on the ipsilateral face and contralateral trunk and limbs, ipsilateral Horner’s syndrome (unilateral ptosis, pupillary constriction, and facial anhidrosis), and such cerebellar signs as ataxia and vertigo. Signs of increased ICP (such as altered LOC, bradycardia, widening pulse pressure, and elevated systolic pressure) may also occur.

Other causes

Drugs and alcohol

Jerk nystagmus may result from barbiturate, phenytoin, or carbamazepine toxicity or from alcohol intoxication.

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Nystagmus: Principal Causes of Nystagmus
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Physiologicnystagmus
    1. Voluntarynystagmus
    2. End-point nystagmus
    3. Opticokinetic nystagmus
    4. Evoked vestibular nystagmus
  2. Pathologic nystagmus
    1. Idiopathiccongenital nystagmus
    2. Latent nystagmus
    3. Nystagmus associated with visual loss
    4. Neurologic disorders associated withnystagmus
      1. Acquiredfixation nystagmus
      2. Periodic alternating nystagmus
      3. Gaze-evoked nystagmus
      4. Seesaw nystagmus
      5. Vestibular nystagmus
        1. Peripherallesions
        2. Central lesions
    5. Spasmus nutans

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Involuntary Movements: Principal Causes of Involuntary Movements
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Tics
    1. Transienttic disorder
    2. Tourette syndrome
    3. Drugs
  2. Chorea
    1. Sydenham chorea
    2. Benign familial chorea
    3. Huntington disease
    4. Drugs
  3. Athetosis
  4. Dystonia
    1. Dopa-responsive dystonia
    2. Idiopathic torsion dystonia (dystoniamusculorum deformans)
    3. Hypoxic-ischemic encephalopathy
    4. Wilson disease
    5. Hallervorden-Spatz disease
    6. Drugs
  5. Myoclonus
    1. Benign neonatal sleep myoclonus
    2. Essential myoclonus
    3. Myoclonic encephalopathy
    4. Other
  6. Tremor
    1. Physiologic tremor
    2. Pathologic tremor
  7. Spasmus nutans
  8. Ballismus
  9. Habit spasms

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Ocular deviation: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain tumor.The nature of ocular deviation depends on the site and extent of the brain tumor. Associated signs and symptoms include headaches that are most severe in the morning, behavioral changes, memory loss, dizziness, confusion, vision loss, motor and sensory dysfunction, aphasia and, possibly, signs of hormonal imbalance. The patient's LOC may slowly deteriorate from lethargy to coma. Late signs include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and decorticate posture.

Cavernous sinus thrombosis.With cavernous sinus thrombosis, ocular deviation may be accompanied by diplopia, photophobia, exophthalmos, orbital and eyelid edema, corneal haziness, diminished or absent pupillary reflexes, and impaired visual acuity. Other features include a high fever, headache, malaise, nausea and vomiting, seizures, and tachycardia. Retinal hemorrhage and papilledema are late signs.

Diabetes mellitus.A leading cause of isolated third cranial nerve palsy, especially in the middle-aged patient with long-standing mild diabetes, diabetes mellitus may cause ocular deviation and ptosis. Typically, the patient also complains of the sudden onset of diplopia and pain.

Encephalitis.Encephalitis causes ocular deviation and diplopia in some cases. Typically, it begins abruptly with fever, headache, and vomiting, followed by signs of meningeal irritation (for example, nuchal rigidity) and neuronal damage (for example, seizures, aphasia, ataxia, hemiparesis, cranial nerve palsies, and photophobia). The patient's LOC may rapidly deteriorate from lethargy to coma within 24 to 48 hours after onset.

Head trauma.The nature of ocular deviation depends on the site and extent of head trauma. The patient may have visible soft-tissue injury, bony deformity, facial edema, and clear or bloody otorrhea or rhinorrhea. Besides these obvious signs of trauma, he may also develop blurred vision, diplopia, nystagmus, behavioral changes, headache, motor and sensory dysfunction, and decreased LOC that may progress to coma. Signs of increased intracranial pressure—such as bradycardia, increased systolic pressure, and widening pulse pressure—may also occur.

Orbital blowout fracture.With an orbital blowout fracture, the inferior rectus muscle may become entrapped, resulting in limited extraocular movement and ocular deviation. Typically, the patient's upward gaze is absent; other directions of gaze may be affected if edema is dramatic. The globe may also be displaced downward and inward. Associated signs and symptoms include pain, diplopia, nausea, periorbital edema, and ecchymosis.

Orbital tumor.Ocular deviation occurs as the orbital tumor gradually enlarges. Associated findings include proptosis, diplopia and, possibly, blurred vision.

Stroke.Stroke, a life-threatening disorder, may cause ocular deviation, depending on the site and extent of the stroke. Accompanying features are also variable and include altered LOC, contralateral hemiplegia and sensory loss, dysarthria, dysphagia, homonymous hemianopsia, blurred vision, and diplopia. In addition, the patient may develop urine retention or incontinence or both, constipation, behavioral changes, headache, vomiting, and seizures.

Thyrotoxicosis.Thyrotoxicosis may produce exophthalmos—proptotic or protruding eyes—which, in turn, causes limited extraocular movement and ocular deviation. Usually, the patient's upward gaze weakens first, followed by diplopia. Other features are lid retraction, a wide-eyed staring gaze, excessive tearing, edematous eyelids and, sometimes, an inability to close the eyes. Cardinal features of thyrotoxicosis include tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance, and an atrial or a ventricular gallop.

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Nystagmus: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain tumor.An insidious onset of jerk nystagmus may occur with tumors of the brain stem and cerebellum. Associated characteristics include deafness, dysphagia, nausea and vomiting, vertigo, and ataxia. Brain stem compression by the tumor may cause signs of increased ICP, such as altered LOC, bradycardia, a widening pulse pressure, and an elevated systolic blood pressure.

Encephalitis.With encephalitis, jerk nystagmus is typically accompanied by altered LOC ranging from lethargy to coma. Usually, it's preceded by sudden onset of fever, headache, and vomiting. Among other features are nuchal rigidity, seizures, aphasia, ataxia, photophobia, and cranial nerve palsies, such as dysphagia and ptosis.

Head trauma.Brain stem injury may cause jerk nystagmus, which is usually horizontal. The patient may also display pupillary changes, an altered respiratory pattern, altered LOC, and decerebrate posture.

Labyrinthitis (acute).Acute labyrinthitis causes a sudden onset of jerk nystagmus, accompanied by dizziness, vertigo, tinnitus, nausea, and vomiting. The fast component of the nystagmus is toward the unaffected ear. Gradual sensorineural hearing loss may also occur.

Ménière's disease.Ménière's disease is characterized by acute attacks of jerk nystagmus, severe nausea and vomiting, dizziness, vertigo, progressive hearing loss, tinnitus, and diaphoresis. Typically, the direction of jerk nystagmus varies from one attack to the next. Attacks may last from 10 minutes to several hours.

Stroke.A stroke involving the posterior inferior cerebellar artery may cause sudden horizontal or vertical jerk nystagmus that may be gaze dependent. Other findings include dysphagia, dysarthria, loss of pain and temperature sensation on the ipsilateral face and contralateral trunk and limbs, ipsilateral Horner's syndrome (unilateral ptosis, pupillary constriction, and facial anhidrosis), and cerebellar signs, such as ataxia and vertigo. Signs of increased ICP (such as altered LOC, bradycardia, a widening pulse pressure, and an elevated systolic pressure) may also occur.

Other causes

Drugs and alcohol.Jerk nystagmus may result from barbiturate, phenytoin, or carbamazepine toxicity or from alcohol intoxication.

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Eye pain [Ophthalmalgia]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acute angle-closure glaucoma.Blurred vision and sudden, excruciating pain in and around the eye characterize acute angle-closure glaucoma; the pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Blepharitis.Burning pain in both eyelids is accompanied by itching, sticky discharge, and conjunctival injection. Related findings include a foreign-body sensation, lid ulcerations, and loss of eyelashes.

Burns.With chemical burns, sudden and severe eye pain may occur with erythema and blistering of the face and lids, photophobia, miosis, conjunctival injection, blurring, and an inability to keep the eyelids open. With ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion.A chalazion causes localized tenderness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis.Some degree of eye pain and excessive tearing occurs with four types of conjunctivitis. Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge. Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it produces burning and a foreign-body sensation. A purulent discharge and conjunctival injection are also typical.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Even without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes, a foreign-body sensation, visible conjunctival follicles, and eyelid edema.

Corneal abrasions.With this type of injury, eye pain is characterized by a foreign-body sensation. Excessive tearing, photophobia, and conjunctival injection are also common.

Corneal ulcers.Bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea; unilateral pupil constriction; and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryocystitis.Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling in the lacrimal punctum area.

Episcleritis.Deep eye pain occurs as tissues over the sclera become inflamed. Related effects include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.

Erythema multiforme major.Erythema multiforme major commonly produces severe eye pain, entropion, trichiasis, purulent conjunctivitis, photophobia, and decreased tear formation.

Foreign bodies in the cornea and conjunctiva.Sudden severe pain is common, but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Hordeolum (stye).Hordeolum usually produces localized eye pain that increases as the stye grows. Eyelid erythema and edema are also common.

Iritis (acute).Moderate to severe eye pain occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.

Lacrimal gland tumor.A lacrimal gland tumor is a neoplastic lesion that usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.

Migraine headache.Migraines can produce pain so severe that the eyes also ache. Additionally, nausea, vomiting, blurred vision, and light and noise sensitivity may occur.

Ocular laceration and intraocular foreign bodies.Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic neuritis.With optic neuritis, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Scleritis.Scleritis produces severe eye pain and tenderness, along with conjunctival injection, a bluish purple sclera and, possibly, photophobia and excessive tearing.

Sclerokeratitis.Inflammation of the sclera and cornea causes pain, burning, irritation, and photophobia.

Subdural hematoma.Following head trauma, a subdural hematoma commonly causes severe eye ache and headache. Related neurologic signs depend on the hematoma's location and size.

Trachoma.Along with pain in the affected eye, trachoma causes excessive tearing, photophobia, eye discharge, eyelid edema and redness, and visible conjunctival follicles.

Uveitis.Anterior uveitis causes the sudden onset of severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.

Posterior uveitis causes an insidious onset of similar features as well as gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Treatments and surgery.Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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Nystagmus as a symptom:

Conditions listing Nystagmus as a symptom may also be potential underlying causes of Nystagmus. Our database lists the following as having Nystagmus as a symptom of that condition: