Causes of Oculogyric Crisis
Oculogyric crisis is primarily caused by medications that block dopamine receptors, particularly antipsychotics and antiemetics, resulting in a hypodopaminergic state that leads to sustained, conjugate upward deviation of the eyes. 1
Medication-Related Causes
Antipsychotic Medications
Typical antipsychotics (most common cause)
- Haloperidol
- Pimozide
- Thioridazine 2
Atypical antipsychotics (less common but documented)
- Quetiapine
- Olanzapine
- Amisulpride
- Lurasidone
- Aripiprazole
- Risperidone 3
Other Medications
- Antiemetics
- Antidepressants
- Antiepileptics
- Antimalarials 6
Pathophysiological Mechanisms
Oculogyric crisis occurs due to:
- Hypodopaminergic state in the basal ganglia
- Imbalance between cholinergic and dopaminergic pathways 7
- Dopamine D2 receptor antagonism leading to extrapyramidal symptoms 2
Risk Factors
Several factors increase the risk of developing oculogyric crisis:
- Age: Younger patients (especially <30 years) 4
- Gender: Male sex 6
- Dosage: Higher doses of dopamine-blocking agents
- Administration route: Parenteral administration increases risk
- Medication potency: Higher potency neuroleptics carry greater risk
- Medication changes: Abrupt discontinuation of anticholinergic medication
- Genetics: Family history of dystonia 6
- Duration: First 24-48 hours of treatment with metoclopramide or other causative agents 4
Non-Medication Causes
While medications are the most common cause, other etiologies include:
- Neurological disorders:
- Postencephalitic parkinsonism (historically the first described cause)
- Parkinson's disease
- Wilson's disease
- Metabolic disorders
- Focal brain lesions 6
Clinical Presentation
Oculogyric crisis typically presents with:
- Sustained dystonic, conjugate, upward deviation of the eyes
- Preserved awareness (patient remains conscious)
- Associated features may include:
- Blepharospasm
- Neck flexion
- Jaw opening with/without tongue protrusion
- Autonomic symptoms 7
Differential Diagnosis
Important to distinguish from:
- Versive seizures
- Paroxysmal tonic upward gaze
- Encephalopathy
- Ocular tics
- Ocular dyskinesia
- Ocular bobbing 7, 5
Understanding the causes of oculogyric crisis is essential for prompt recognition and appropriate management, as early intervention with anticholinergic medications can rapidly resolve symptoms and prevent recurrence.