How to treat nystagmus?

From the Guidelines

Treatment for nystagmus should be individualized based on its underlying cause, and may involve a combination of medications, optical treatments, and surgery to improve symptoms and quality of life. For acquired nystagmus, addressing the primary condition is essential, which may involve treating infections, reducing inflammation, or managing neurological disorders 1. Medications commonly prescribed include baclofen, gabapentin, memantine, or clonazepam, which help reduce abnormal eye movements by affecting neurotransmitters in the brain. Optical treatments like specialized glasses or contact lenses can sometimes help stabilize vision. Botulinum toxin injections into eye muscles may temporarily reduce nystagmus intensity in some cases.

For congenital nystagmus, which is present from birth, treatment focuses on vision improvement through corrective lenses and sometimes surgery to reposition eye muscles 1. Vision therapy exercises may help patients develop compensatory strategies. Some patients benefit from the "null point" technique, positioning their head to minimize eye movements. It's also important to establish priorities in the goal-directed management of strabismus, including improved eye contact and appearance of alignment, enhancement of binocular potential, or reduction or resolution of diplopia and/or compensatory head posture 1.

Key considerations in treating nystagmus include:

• Identifying and addressing the underlying cause of nystagmus
• Using a combination of medications, optical treatments, and surgery as needed to improve symptoms and quality of life
• Regular follow-up with an ophthalmologist or neuro-ophthalmologist to monitor progress and adjust treatment as needed
• Informing the patient’s primary care and other health care providers of the diagnosis, treatment plan, and the value of the intervention 1.

From the Research

Treatment Options for Nystagmus

The treatment of nystagmus depends on the characteristics of the nystagmus and the severity of the associated visual symptoms. Several treatment options are available, including:

• Pharmacologic treatments:
  • Downbeat nystagmus can be treated with 4-aminopyridine, 3,4-diaminopyridine, or clonazepam 2, 3, 4
  • Upbeat nystagmus can be reduced with memantine, 4-aminopyridine, or baclofen 2, 4
  • Torsional nystagmus may respond to gabapentin 2
  • Acquired pendular nystagmus in patients with multiple sclerosis is often partially suppressed by gabapentin or memantine 2, 5, 4
  • Acquired pendular nystagmus in patients with oculopalatal tremor can respond to gabapentin, memantine, or trihexyphenidyl 2, 5
• Optical treatments:
  • Contact lenses can be used in infantile nystagmus to overcome negative effects of eye glasses in abnormal head posture, lateral gaze, and higher refractive errors 6
  • Spectacle prisms are useful to induce an artificial exophoria (base-out prisms) or to shift an excentric null zone (base in direction of head posture) of infantile nystagmus with abnormal head posture 6
  • Low vision aids may be necessary and should be prescribed according to magnification requirements 6
• Surgical treatments:
  • Several surgical therapies have been reported to improve infantile nystagmus syndrome (INS), but selection of the appropriate therapy requires preoperative evaluation of visual acuity and nystagmus intensity in different gaze positions 2, 5
  • Unilateral recess-resect surgery of the dominant eye in infantile esotropia with latent nystagmus for the relief of abnormal head posture 6
  • Kestenbaum operation of both eyes in infantile nystagmus syndrome with excentric null zone and abnormal head posture 6
  • Recess-resect surgery to produce artificial exophoria in infantile nystagmus syndrome 6

Pharmacological Treatment

Pharmacological treatment depends on the type of nystagmus and its characteristics. The following drugs have been effective in clinical application:

• Gabapentin: up to 2400 mg/d in infantile nystagmus, acquired pendular nystagmus and oculopalatal tremor 6
• Memantine: dosage up to 40 mg/d in infantile nystagmus, also in acquired pendular nystagmus and oculopalatal tremor 6
• Baclofen: 3 × 5-10 mg/d in periodic alternating nystagmus and in upbeat nystagmus 6
• 4-aminopyridine: 3 × 5 mg/d or 1-2 × 10 mg Fampridin in downbeat nystagmus and upbeat nystagmus 6
• Acetazolamide: in hereditary episodic ataxia type 2 6

Electro-Optical Devices

Electro-optical devices are a promising and novel approach for treating the visual consequences of acquired forms of nystagmus 2, 5