Pathophysiology of vertical nystagmus in infancy

Abstract : Studying infantile nystagmus during infancy is difficult for methodological reasons. Most such studies have been performed in adults and a posteriori. These studies in adults allowed for an improvement in the existing classifications, with now robust knowledge about the two most frequent varieties of infantile nystagmus: infantile nystagmus syndrome and fusion maldevelopment nystagmus syndrome. The characteristics and pathophysiology of nystagmus in infants–notably varieties of nystagmus with a vertical component and transitory nystagmus– need further study. For this reason: 1. We developed new techniques for the recording of eye movements in infants in the setting of a clinic. They include new stimuli, the use of specially-designed infrared photo-oculography eyetrackers and new statistical analysis paradigms. We assessed these techniques in a population of 28 infants with a nystagmus. 2. We systematically studied 32 cases of spasmus nutans, classically considered an idiopathic entity, with comprehensive clinical examination, brain imaging, electrophysiology, nystagmus recording. In 53.1% of cases, it led to the diagnosis of another condition: a neurological disease (34.3%), including cases of chiasmal gliomas (21.9%), or a retinal dysfunction (12.5%). Anterior visual pathway dysfunction is likely involved in the pathophysiology of spasmus nutans. 3. Eight cases of nystagmus having led to a diagnosis of optic pathway glioma (OPG) were also recorded and studied. Age at nystagmus onset was 2.5-10 months. The associated OPG always involved the chiasm, and represent a specific subpopulation of OPG. Clinically, the nystagmus was always classified as spasmus nutans type. Oculographic recordings showed frequencies of 2.7-5 Hz, sinusoidal waveforms, dissociation and a special type of disconjugacy, with a 180° horizontal phase shift and no vertical phase shift, exhibiting a “convection-like” movement pattern. Rarely and for short periods of time, the phase shift could change. These characteristics point towards oscillations in the vergence system, which could possibly result from the specific disruption of the vergence centres afferences in the brainstem, induced by the OPG during the sensitive period of visual development. 4. Five cases of upbeat nystagmus in infants with normal retinas and normal brain imaging were studied. The nystagmus mostly occurred in supine position and could be triggered by head rotations in the supine position. All resolved spontaneously. The characteristics of this nystagmus suggest an involvement of the otolithic system, with a secondary recalibration of the vestibulo-ocular pathways. In conclusion, the development of infant-friendly devices for eye-movements recording helps providing new insights on the pathophysiology of poorly described varieties of nystagmus, including nystagmus with a vertical component and transitory nystagmus. The maturation process of both the anterior visual pathways and the oculomotor pathways appears to be central in the mechanisms of these nystagmus.
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Matthieu Robert. Pathophysiology of vertical nystagmus in infancy. Neuroscience. Université Sorbonne Paris Cité, 2016. English. ⟨NNT : 2016USPCB008⟩. ⟨tel-01584471⟩

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