What is the treatment for an oculogyric crisis?

Treatment of Oculogyric Crisis

The first-line treatment for oculogyric crisis is immediate administration of parenteral anticholinergic medication, specifically intramuscular benztropine 1-2 mg or intravenous/intramuscular diphenhydramine 25-50 mg, which typically provides quick relief within minutes to an hour. 1, 2, 3

Understanding Oculogyric Crisis

Oculogyric crisis (OGC) is an acute dystonic reaction characterized by:

• Sustained, bilateral, and upward deviation of the eyes
• Often accompanied by neck flexion, blepharospasm, jaw opening with/without tongue protrusion
• Preserved consciousness/awareness
• Possible autonomic symptoms
• Significant distress for patients

Causes

OGC is primarily medication-induced, resulting from:

• Dopamine receptor blocking agents (most common cause)
• Typical antipsychotics (e.g., haloperidol)
• Atypical antipsychotics (less commonly)
• Antiemetics (e.g., metoclopramide, promethazine)
• Phenothiazines

Risk factors include:

• Young age
• Male gender
• First exposure to antipsychotics
• Recent medication initiation or dose increase 3, 4

Treatment Algorithm

Acute Management

1. First-line treatment:

   • Parenteral anticholinergic medication:
     • Benztropine 1-2 mg IM/IV 2
     • OR Diphenhydramine 25-50 mg IM/IV 1, 3

2. If symptoms persist:

   • Repeat anticholinergic dose after 30 minutes
   • Consider adding a benzodiazepine (e.g., lorazepam) if needed

3. After acute resolution:

   • Continue oral anticholinergic therapy for 2-3 days to prevent recurrence 5
   • Oral diphenhydramine 25-50 mg TID or benztropine 1-2 mg BID

Long-term Management

1. Identify and address the causative agent:

   • Hold or discontinue the offending medication if possible
   • If antipsychotic therapy must continue:
     • Reduce the dose of current antipsychotic 4
     • OR Switch to an antipsychotic with lower risk of extrapyramidal symptoms
     • Consider clozapine for refractory cases 4, 6

2. Prophylaxis:

   • For patients requiring continued treatment with high-risk medications, consider prophylactic anticholinergic therapy

Special Considerations

• Monitoring: Patients experiencing OGC should be monitored for at least 1-2 hours after treatment to ensure complete resolution of symptoms
• Differential diagnosis: Rule out seizures, functional neurological disorders, ocular tics, and other causes of abnormal eye movements 5
• Psychosis exacerbation: OGC may be associated with worsening of psychotic symptoms in patients with psychiatric disorders 6

Important Caveats

• Anticholinergic medications can have side effects including sedation, dry mouth, urinary retention, and confusion
• In elderly patients, use lower doses of anticholinergics due to increased sensitivity to side effects
• Avoid using promethazine to treat OGC, as it can paradoxically worsen symptoms due to its own potential to cause extrapyramidal effects 1
• Parenteral administration of anticholinergics provides faster relief than oral administration in acute cases
• For medication-induced OGC that does not respond to anticholinergics, switching to a different class of medication may be necessary 4

By promptly recognizing and treating oculogyric crisis with appropriate anticholinergic medications, symptoms can typically be resolved quickly, preventing unnecessary distress and potential complications.