An oculogyric crisis is a type of dystonia in which the affected person has no control over the symptoms and the extent of the neurological and psychological symptoms. The crisis may last a few minutes or much longer.
What is an oculogyric crisis?
The term crisis always stands for a kind of aggravation. A problematic situation arises that usually requires a quick response. This is exactly what applies to the oculogyre crisis. It is a type of dystonia (neurological movement disorder) in which the eyeballs slide uncontrollably in a certain direction (tonic lateral movement). Those affected by an oculogyric crisis are unable to exert any influence. Diseases of the basal ganglia (core areas below the cerebral cortex), psychogenic or drug toxic causes can be responsible for an oculogyric crisis. In professional circles one speaks of a non-epileptic movement disorder (movement disorder without falling sickness or seizure disorder). This disease is classified in the field of neurology or psychiatry. The crisis is defined by different communication disorders, very differentiated neurological features, and psychological and physical features of different genesis. Once the crisis is over, a mild or pronounced state of exhaustion may occur in those affected.
Causes
From the range of drug treatments, neuroleptics such as haloperidol and olanzapine, respectively, carbamazepine, cisplatin, chloroquine, diazoxide, metoclopramide, nifedipine, domperidone, pemoline, phencyclidine, and levopoda are possible causes of an oculogyric crisis. These neuroleptics (from neuron: “nerve”, lepsis: “to seize”) combat the loss of reality in correspondingly ill people due to their sedative and antipsychotic effects. Severe mental disorders, fears, anxieties and delusions as well as hallucinations are also treated with neuroleptics, more recently called antipsychotics. Other causes of oculogyric crisis are found in Parkinson’s disease, Tourette’s syndrome, and multiple sclerosis. Postencephalitic Parkinson’s syndrome was considered the main causative agent until after 1920. Since in recent times also ADHD in children as well as Fetal Alcohol Syndrome and Autism are treated with neuroleptics, these diseases must also be considered as secondary causative agents because of the drug effect. Because in severe cases, obsessive-compulsive disorders, personality disorders, and pathological arousal disorders are also medicated with a neuroleptic, these disorders must additionally be included in the list of diseases that can cause an oculogyric crisis because of the drug effect. Basal ganglia disorders and psychogenic signs can cause an oculogyric crisis.
Symptoms, complaints, and signs
Initial symptoms may include, for example, agitation, restlessness, and malaise but also a fixed gaze. Subsequently, symptomatic upward movement of the eyes may occur. Head movements backward or to the side, as well as a wide-open mouth and eye pain, may also occur. After the crisis, a state of exhaustion cannot be ruled out. In the course of a crisis, multism (communication disorder, psychogenic silence without defect of the organs of speech) and palilalia (pathological compulsion to repeat one’s own words and sentences) are known as well as blinking of the eyes, lacrimation and pupil dilation. Other symptomatology during a crisis may include hypertension, headache, salivation, depression and paranoia, as well as obsessive thoughts and depersonalization. The use of obscene vocabulary as well as violence has been reported as well. An oculogyric seizure is defined as an epileptic seizure with a tonic lateral movement of the eyes.
Diagnosis and course of the disease
As oculogyric crises progress, not only recurrence but also spread of focal dystonia can be expected. Namely, to other muscle groups. Comparable symptoms of Meige syndrome may occur.
Complications
Oculogyric crisis, the spasmodic upward movement of the eyes, is already a complication in the setting of a neurologic or neurodegenerative disease. The crisis can also be triggered by taking certain medications. Usually, in addition to the upward movements of the eyes, only head movements to the back or to the side with the mouth open occur.However, oculogyric crisis may also be associated with other serious complications. In addition to sudden onset of severe hypertension, headache, lacrimation, pupil dilation, and profuse salivation, delusions, depression, depersonalization, and violent outbursts may also occur. Symptoms may worsen if the affected person is restrained with force. Therefore, it is important to remain calm during an attack. However, uninvolved persons may be injured during a sudden violent outburst by the patient. Furthermore, it can also happen that the affected person hurts himself, for example by biting his tongue. To avoid serious complications, the patient should be cared for as closely as possible. He should be accompanied when traveling or carry an emergency card with him so that proper action can be taken in an emergency. Sharp objects should be kept out of reach, as the patient may endanger himself and others. Stress and excitement have a counterproductive effect in a state of seizure.
When should one go to the doctor?
A visit to the doctor is necessary as soon as the affected person shows unusual changes in personality or behavior. If the appearance is perceived as deviating from the norm, action is needed. A fixed gaze, hallucinations or delusions are cause for concern and must be clarified by a physician. Dilated pupils, persistent fatigue, and depressive states must be presented to a physician. The affected person needs help as well as drug therapy. In case of uncontrollable salivation, upward movements of the eyes or pain, investigations should be initiated. A diagnosis is needed so that a treatment plan can be established. If the affected person responds unusually or not at all to social interactions, a health disorder is present. Persistent tearing, an open mouth, or unusual posture should be presented to a physician. Obsessive acts or obsessions are other signs of an irregularity. If the listed complaints persist over a longer period of time or if there is an increase in symptoms, a visit to the doctor is necessary. In case of high blood pressure as well as a backward tilted head posture, a doctor should be consulted. If seizures occur, sudden violent outbursts occur, or there is evidence of depersonalization, a doctor should be consulted immediately. In severe cases, an ambulance must be alerted. Until its arrival, measures of injury containment are necessary to avoid serious complications.
Treatment and therapy
If an acute oculogyric seizure occurs, remain calm. Under no circumstances should the affected person be restrained by force. Inserting objects into the mouth to prevent tongue biting should also be avoided. Instead, the person should be placed in a protected body position with head support. It is also important not to leave the affected person alone, to loosen their clothing and possibly remove their glasses. All objects that could endanger the person should be moved out of reach. Bystanders should be reassured to avoid causing further stress. The next of kin (life partner, parents) as well as the doctor should be informed as soon as possible. Once the seizure is over, the affected person can be spoken to with calming words and taken to a quiet place (separate room or quiet corner). An emergency card with all relevant information (exact diagnosis, therapy, rules of conduct) should be carried at all times for the best possible first aid. Initial medical treatment for an oculogyric crisis can consist of intravenous administration of benzatropine. An effect usually occurs after about five minutes. However, full effect may not occur for half an hour.
Outlook and prognosis
An oculogyric crisis is a concomitant of a present illness. It is a medical emergency that must be treated as a matter of principle. Otherwise, the general health of the affected person may permanently deteriorate to a significant degree. In addition, violent outbursts may occur, which pose a potential danger to the person affected and to bystanders. Medical care is needed as quickly as possible so that the state of crisis can be overcome.Patients present with diseases that are mostly chronic in nature. Although the prognosis depends on the development of the underlying disease, recovery is often not to be expected. Rather, long-term therapy is necessary to allow stabilization of the health condition. In some cases, the cause can be found in the administration of neuroleptics. If there is the possibility of being able to discontinue these drugs permanently because the underlying mental illness has been treated, there is also a significant improvement in the health of the person affected. The best prospects are for people suffering from obsessive-compulsive disorder. Here, good therapeutic successes can be achieved in a professional treatment. The cooperation of the patient is absolutely necessary. Improvement is more difficult in the case of personality disorders or addictive disorders. Here, the prognosis is worse overall.
Prevention
As with other neurodegenerative diseases, a molecular pathologic diagnosis should be made. This is based on current developments in causal therapeutic approaches. Close collaboration in primary care with specialized centers is essential for this. Those who know that an oculogyric crisis can occur at any time should keep visual targets in the distance in the car, on the bus, or while riding the train in view. In this way, one’s own visual control can be exercised. Logopedic care as well as physiotherapeutic measures are recommended to avoid new oculogyric seizures if possible or at least to limit their intensity. Adjunctive drug therapy is essential in most cases.
Follow-up care
After a gaze seizure, the physician should be consulted at least one more time. Follow-up care for an oculogyric crisis focuses on various physical examinations and a patient interview. The physician assesses the risk for recurrence and clarifies any unanswered questions the patient may have as part of the medical history. In some cases, the physician consults a therapist, especially in cases of severe seizures associated with physical deficits. An examination of the eyes is performed to rule out damage. If there are injuries to the eyes or as a result of an accident to other parts of the body, these are diagnosed and treated. The general practitioner consults other specialists for this purpose. After the treatment has been completed, the patient must visit the doctor again so that he or she can complete the follow-up examination. If necessary, the medication the patient is taking must be readjusted. During follow-up, additional measures are also discussed, such as the prevention of epileptic seizures or the prescription of an emergency medication. The necessary steps are then taken to correct the causes and optimize the patient’s safety. Follow-up care is provided by the responsible ophthalmologist or general practitioner.
What you can do yourself
In the event of an oculogyric seizure, the emergency physician must be called. The affected person should take the emergency medication and then lie on his or her back. If the seizure is severe, any first responders must reassure the affected person and also give the person the antiepileptic drugs, if necessary. The paramedic must be informed about the condition so that the necessary measures can be taken immediately. In the case of a mild seizure, the sufferer will usually have recovered within half an hour. In the case of a severe seizure, hospitalization is necessary. The patient should take sufficient rest and avoid stress. The diet does not have to be changed after an oculogyric crisis. The most important self-help measure is to always carry the emergency medication and to avoid seizures by a prudent lifestyle. Sufferers should avoid flashing lights and loud and rapid sounds. An emergency card must also be carried so that the necessary steps can be taken in the event of an emergency. Finally, it is important to optimally adapt one’s living conditions to the symptoms in order to avoid risking a seizure and to receive the necessary help immediately in the event of a seizure. The doctor in charge can give further tips for accompanying self-therapy.