What are rolling eye movements?

Rolling Eye Movements: Clinical Characteristics and Diagnostic Significance

Rolling eye movements refer to specific patterns of eye movement that can indicate various vestibular or neurological conditions, most commonly seen in benign paroxysmal positional vertigo (BPPV) during diagnostic maneuvers, or in certain central nervous system disorders.

Types of Rolling Eye Movements

• Torsional nystagmus: Rotational eye movements that occur during the Dix-Hallpike test for posterior canal BPPV, characterized by upbeating and torsional components when the affected ear is positioned downward 1, 2

• Horizontal nystagmus: Side-to-side eye movements seen during the supine roll test for lateral canal BPPV, which can be either:

  • Geotropic: Beating toward the undermost ear (more common) 2
  • Apogeotropic: Beating toward the uppermost ear 2

• Ocular tilt reaction (OTR): A triad of head tilt, skew deviation (vertical misalignment of eyes), and ocular torsion that can appear as rolling eye movements, typically seen with brainstem lesions 1, 3

Diagnostic Significance

BPPV-Related Rolling Eye Movements

• Rolling eye movements in BPPV occur because crystals (otoconia) become dislodged from their normal position and float in the semicircular canals of the inner ear 1

• These movements are triggered by specific position changes and have characteristic patterns:

  • Posterior canal BPPV: Torsional upbeating nystagmus during Dix-Hallpike test 2
  • Lateral canal BPPV: Horizontal nystagmus during supine roll test 2

• The intensity of symptoms correlates with the time it takes for the crystals to settle after head movement 1

Central Nervous System Disorders

• Skew deviation: Vertical misalignment of the eyes with torsional components, associated with brainstem or cerebellar disorders 1

• Sagging eye syndrome: Esotropia (inward eye deviation) with small vertical and torsional components, typically seen in older adults due to degeneration of connective tissue supporting the lateral rectus muscle 1

• Myopic strabismus fixus (heavy eye syndrome): Severe esotropia with hypotropia and limited eye rotation in patients with high myopia, causing abnormal eye movements 1

Diagnostic Approach

• Dix-Hallpike test: The primary diagnostic maneuver for posterior canal BPPV, involves moving the patient from sitting to lying with the head turned 45° to one side and extended 20° below horizontal 1, 2

• Supine roll test: Used to diagnose lateral canal BPPV by quickly rotating the patient's head 90° to each side while in supine position and observing for nystagmus 2

• Ocular motility examination: Should include assessment of:

  • Eye position and alignment 4
  • Range of eye movements 4
  • Smooth pursuit and saccades 5
  • Vestibulo-ocular reflex 5
  • Presence of nystagmus in different gaze positions 5

• Neuroimaging: Indicated when central causes are suspected, particularly with:

  • Abduction nystagmus suggesting 6th nerve palsy 1
  • Signs of elevated intracranial pressure 1
  • Persistent or atypical eye movement patterns 1

Common Pitfalls and Caveats

• Rolling eye movements must be distinguished between peripheral (e.g., BPPV) and central causes, as management differs significantly 2

• Avoid routine use of vestibular suppressant medications for BPPV as they may delay central compensation 2

• Exercise caution when performing diagnostic maneuvers in patients with cervical stenosis, severe kyphoscoliosis, or limited cervical range of motion 2

• Normal medical imaging (scans, x-rays) cannot confirm BPPV; diagnosis relies on clinical examination and characteristic eye movements 1

• Functional (psychogenic) eye movement disorders can mimic pathological eye movements and should be considered in the differential diagnosis 6