From the Guidelines
Vertical ocular flutter causes rapid, involuntary, vertical eye movements without an intersaccadic interval, typically resulting from damage to the brainstem or cerebellum, and is characterized by brief bursts of up-and-down oscillations of the eyes while maintaining normal horizontal gaze. This condition is often associated with underlying causes such as stroke, multiple sclerosis, paraneoplastic syndromes, viral encephalitis, or other inflammatory conditions affecting the brainstem or cerebellum 1. The pathophysiology of vertical ocular flutter involves disruption of the neural integrator circuits that normally maintain stable eye position, leading to these abnormal oscillatory movements. Patients may experience visual disturbances, dizziness, or imbalance during episodes, and treatment focuses on addressing the underlying cause rather than the eye movements themselves. Some patients may respond to medications like clonazepam, valproic acid, or memantine that can dampen abnormal neural activity in the cerebellum and brainstem. Key characteristics of vertical ocular flutter include:
- Brief bursts of up-and-down oscillations of the eyes
- Maintenance of normal horizontal gaze
- Association with brainstem or cerebellum damage
- Underlying causes such as stroke, multiple sclerosis, or inflammatory conditions
- Disruption of neural integrator circuits leading to abnormal oscillatory movements
- Potential treatment with medications like clonazepam, valproic acid, or memantine, as supported by recent studies 1.
From the Research
Vertical Ocular Flutter
- Vertical ocular flutter is a type of saccadic intrusion characterized by spontaneous, back-to-back, fast eye movements that oscillate about the midline of central visual fixation without intervening inter-saccadic intervals 2.
- It occurs exclusively in the vertical plane, as opposed to ocular flutter which occurs in the horizontal plane, and opsoclonus which occurs in multiple planes (i.e. horizontal, vertical, and torsional) 2, 3.
- The mechanism of vertical ocular flutter relates to dysfunction of brainstem and cerebellar machinery involved in the generation of saccades 2.
- Rotatory nystagmus, which involves both vertical and horizontal ocular flutter, is saccadic in nature and arises from a unique timing relationship between vertical and horizontal flutter 4.
Causes of Vertical Ocular Flutter
- Vertical ocular flutter can be caused by a broad array of neuropathologies, including parainfectious and paraneoplastic diseases, toxic-metabolic, traumatic, or idiopathic origins 2.
- It can also be a presenting manifestation of pediatric MOG antibody-associated demyelination 5.
- In some cases, vertical ocular flutter can be a paroxysmal manifestation of brain stem demyelination, such as in suspected multiple sclerosis 6.