What is the clinical significance of rolling eyes in a patient with a potential mental health condition, and how should it be evaluated and managed?

Rolling Eyes in Mental Health: Clinical Significance and Management

"Rolling eyes" in a patient with potential mental health concerns requires immediate differentiation between neurological eye movement disorders (including tics, functional eye movements, and vestibular pathology) versus behavioral manifestations, with the evaluation prioritizing identification of organic causes that could impact morbidity before attributing symptoms to psychiatric etiology alone.

Primary Differential Diagnosis

Neurological Eye Movement Disorders

Eye movement tics are a core feature of Tourette syndrome and occur in 78.3% of patients with Gilles de la Tourette syndrome (GTS), manifesting as rolling eyes up/down, eyes looking sideways, or staring. 1 These patients typically have earlier age of onset (7.1 years) and higher tic severity correlates with lifetime history of eye movement tics. 1

Functional (psychogenic) eye movement disorders represent a distinct category that may present with ocular symptoms including blurred vision or oscillopsia, with convergence spasm being the most common type. 2 Other manifestations include:

• Functional gaze limitation 2
• Functional eye oscillations (voluntary nystagmus) 2
• Functional convergence paralysis 2

Vestibular Pathology Requiring Urgent Evaluation

If the patient reports vertigo or dizziness with eye rolling, perform the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV, which presents with torsional, upbeating nystagmus when the affected ear is down. 3 If negative or showing horizontal nystagmus, the American Academy of Otolaryngology-Head and Neck Surgery recommends performing the supine roll test for lateral canal BPPV. 4, 3

The supine roll test involves positioning the patient supine with head neutral, quickly rotating the head 90 degrees to one side while observing for nystagmus, with horizontal nystagmus beating toward the undermost ear indicating geotropic-type lateral canal BPPV. 4, 3

Critical Evaluation Framework

Immediate Assessment Components

Perform a systematic mental status examination assessing appearance, behavior, thought process, thought content, mood and affect, insight and judgment, followed by structured cognitive testing across attention, memory, executive function, language, and visuospatial abilities. 5

Evaluate for underlying medical conditions through vital signs, physical examination, delirium screening, laboratory testing, and neuroimaging for patients with altered mental status, new-onset psychiatric symptoms, or acute changes in behavior. 5 This is critical because mental health disorders can influence perception of ocular symptoms without corresponding objective findings. 6

Ophthalmological Examination Requirements

Conduct comprehensive eye evaluation including:

• Visual acuity testing with and without correction 7
• Cycloplegic refraction to rule out pseudomyopia (inappropriately excessive accommodation due to ciliary spasm associated with anxiety and psychiatric illness) 8
• Funduscopic examination of optic disc, macula, retina, vessels, and choroid 7
• Assessment for strabismus, which occurs frequently in individuals with mental illness 9
• Evaluation for uncorrected refractive error, blepharitis, and pigmentary retinopathy (common in mentally ill populations) 9

Psychiatric-Ophthalmological Interface

Anxiety and Accommodation Disorders

Generalized anxiety disorder is the most common psychiatric illness associated with pseudomyopia, with positive correlation between anxiety-somatization scores and accommodation amount of the eye. 8 The mechanism involves psychological stress affecting the autonomic nervous system, with parasympathetic activation causing ciliary muscle contraction. 8

A psychiatric consultation should be included in the multidisciplinary evaluation of every case where eye symptoms appear disproportionate to objective findings. 8, 6

Depression and Visual Symptoms

Depression, anxiety, stress, hypochondriasis, neuroticism, and mood disorders may be associated with exacerbation of ocular symptoms to degrees inconsistent with objective signs. 6 Vision loss itself is significantly associated with depression and adverse effects on quality of life and mental health. 7

Management Algorithm

Step 1: Rule Out Organic Causes

• Complete neurological examination for tic disorders 1
• Vestibular testing if vertigo present 4, 3
• Comprehensive ophthalmological evaluation 7
• Neuroimaging if atypical features, rapid progression, or neurological symptoms present 5

Step 2: Identify Psychiatric Comorbidity

• Use validated screening instruments (MoCA, MMSE for cognitive function; Neuropsychiatric Inventory-Q, Geriatric Depression Scale for mood) 5
• Assess for anxiety disorders, depression, and stress-related conditions 8, 6
• Evaluate for risk factors requiring inpatient psychiatric admission (persistent suicidal ideation, severe agitation or psychosis, comorbid substance abuse) 5

Step 3: Multidisciplinary Treatment Based on Etiology

For tic disorders: Eye tics should be routinely evaluated as a core feature of GTS to strengthen diagnostic confidence. 1

For functional eye movement disorders: Diagnosis and management require specialized ophthalmological expertise with consideration of psychiatric consultation. 2

For anxiety-related pseudomyopia: Use multidisciplinary approach including psychiatric consultations, work environment changes, ocular exercises, and cycloplegic drugs. 8

For BPPV: Treat posterior canal BPPV with canalith repositioning procedure (Epley maneuver); treat lateral canal BPPV with Barbecue roll or Gufoni maneuver depending on variant. 3 Avoid routine vestibular suppressant medications as they may delay central compensation. 3

Step 4: Address Vision Rehabilitation Needs

Recommend psychological therapies such as support groups for patients with vision loss, as they show moderate effect on depression versus usual care. 7 Stepped care interventions added to usual vision rehabilitation lead to significant reduction in incidence of major depressive, dysthymic, and anxiety disorders (absolute difference 17%). 7

Critical Pitfalls to Avoid

Do not attribute eye rolling solely to psychiatric causes without comprehensive ophthalmological and neurological evaluation, as individuals with mental illness frequently exhibit uncorrected refractive error, strabismus, and other ocular anomalies that require specific treatment. 9

Do not dismiss patient-reported visual symptoms even when objective findings are minimal, as mental health disorders can genuinely influence symptom perception and require integrated psychiatric-ophthalmological management. 6

Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms, and evaluate for unresolved pathology or alternative diagnoses if symptoms persist. 3