Nystagmus Types

Issues of Concern

Nystagmus, in some patients, can be asymptomatic. However, in most, nystagmus causes vertigo, oscillopsia, blurred vision, or abnormal head positioning. Vertigo is the primary symptom and occurs most commonly with vestibular problems. Oscillopsia, a sensation of the environment moving back and forth, depends on the type of nystagmus present but can be continuous, intermittent, or gaze-evoked.[5]  Blurred vision usually occurs due to the motion affecting the retinal image. This blurred vision can lead to abnormal head positioning when patients compensate for their vision changes by finding gaze positions that minimize their symptoms.

Clinical Significance

A major concern with finding pathological nystagmus is localizing the abnormal brain or ear apparatus structures affected and what is the underlying etiology. For instance, acquired nystagmus, which develops later in adolescence or adulthood, can indicate a central nervous system issue like multiple sclerosis, head injury, brain tumor, metabolic disorder, medication side effects, hyperventilation, or even alcohol or drug toxicity.[6][7][8][9][10] The differential diagnosis of nystagmus also includes oculogyric crises and ocular bobbing. Oculogyric crises are distinguishable from nystagmus by noting a lack of a specific rhythm or slow phase with eye movements. This type of eye movement most commonly presents with phenothiazine intoxication. Ocular bobbing is more irregular than nystagmus and usually occurs in locked-in syndrome.

Pathological nystagmus: abnormal nystagmus from central or peripheral nervous system damage to the vestibular-oculocephalic or cortical areas affecting the oculomotor function

• Spontaneous nystagmus: occurs consistently with fixed central gaze position stationary, upright, and neutral positions.
• Spontaneous peripheral vestibular nystagmus: occurs due to abnormal vestibular tone between vestibular nerves and the labyrinth; it is strictly unilateral and can be subclassified based on the direction.
  • Horizontal-torsional nystagmus
  • Vertical-torsional nystagmus
  • Horizontal-vertical-torsional nystagmus
  • Peripheral vestibular nystagmus, inhibitory type
  • Peripheral vestibular nystagmus, excitatory type
  • Recovery nystagmus
• Spontaneous central vestibular nystagmus
  • Predominantly horizontal central vestibular nystagmus
    • Direction-fixed horizontal central vestibular nystagmus
    • Latent nystagmus
    • Periodic alternating nystagmus
  • Predominantly vertical or torsional central vestibular nystagmus
    • Downbeat nystagmus
    • Upbeat nystagmus
    • Torsional nystagmus
  • Infantile nystagmus
  • Acquired pendular nystagmus
• Oculomasticatory myorhythmia
• Seesaw nystagmus
• Epileptic nystagmus
• Pursuit-paretic nystagmus
• Gaze-evoked nystagmus
  • Unilateral
  • Bilateral
  • Vertical
  • First-degree vestibular
  • Vestibular plus gaze-holding nystagmus
  • Rebound nystagmus
  • Centripetal nystagmus
• Triggered nystagmus
  • Positional nystagmus
    • Benign paroxysmal positional nystagmus (BPPN)
      • Anterior semicircular canal BPPN 
      • Posterior semicircular canal BPPN
      • Horizontal semicircular canal BPPN
      • Pseudo-spontaneous nystagmus
    • Central positional nystagmus
• Headshaking-induced nystagmus
• Cross-coupled nystagmus
• Sound-induced nystagmus
• Valsalva-induced nystagmus
• Pressure-induced nystagmus
• Vibration-induced nystagmus
• Hyperventilation-induced nystagmus
• Pursuit-induced nystagmus
• Vertical nystagmus 
  • Vertical nystagmus
    • Posterior fossa lesions
    • Medication side effects
    • Vitamin deficiencies
    • Inflammatory and autoimmune/paraneoplastic conditions
    • Hereditary and degenerative cerebellar ataxias.

Nursing, Allied Health, and Interprofessional Team Interventions

All interprofessional healthcare team members should be aware of the nature of nystagmus and, depending on specialty, be capable of varying degrees of interpretation. However, recognizing the condition is essential so the patient can be referred to the appropriate clinician for further workup and diagnosis. It must be charted in the patient's record so that all healthcare team members know that appropriate action can occur, leading to a more accurate diagnosis and improved patient outcomes.