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Drug-induced reverse ocular dipping Naoyuki Kitagawa, Michio Sakurai Department of Neurology, Kohsei Chuo General Hospital, Tokyo, Japan Correspondence to Dr Naoyuki Kitagawa, knaoyuki.neurology@gmail. com Accepted 9 September 2014 To cite: Kitagawa N, Sakurai M. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/bcr-2014- 206951 DESCRIPTION A 19-year-old male patient, who had undergone laminectomy for lumbar disc herniation the previ- ous day, reported involuntary upward movement of his eyes. The eyes exhibited conjugate upward movement, followed by a brief tonic phase, and rapid downward movement to the primary pos- ition. These cycles were repeated at irregular inter- vals (video 1). He was awake and could respond to simple commands and explain his symptoms in his own words. There were no neurological abnormal- ities except abnormal eye movement. After the surgery, droperidol and fentanyl had been adminis- tered by continuous infusion for pain relief. The abnormal eye movements resolved within 2–3h after withdrawal of these drugs (video 1). Brain CT and blood examination revealed no abnormalities. Ocular bobbing is the best known abnormal spontaneous eye movement, and several variants of these movements have been described according to the direction and speed of the drifts. Reverse ocular dipping is one of these variants, first described by Mehler. 1 Abnormal spontaneous eye movements have been shown to be associated with various clinical settings and a few cases of drug-induced abnormal eye movement have been reported. 12 It has been reported that fentanyl can cause transient disturbance of eye fixation with downbeat nystagmus in normal patients. 3 Opioid receptors are located in the medial vestibular nucleus. The activation of opioid receptors in the medial vestibular nucleus inhibits the tonic dis- charge of these cells, which may cause eye fixation abnormalities. 3 In our case, fentanyl may have induced reverse ocular dipping by a similar mechanism. Learning points ▸ Reverse ocular dipping is a rare abnormal eye movement, which could be caused by some drugs. ▸ Opioid may cause eye fixation abnormalities and it could induce reverse ocular dipping. Contributors NK and MS contributed in the drafting/revising the manuscript, study concept or design, analysis or interpretation of data and gave final approval. MS was involved in the acquisition of data. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES 1 Mehler MF. The clinical spectrum of ocular bobbing and ocular dipping. J Neurol Neurosurg Psychiatry 1988;51:725–7. 2 Lennox G. Reverse ocular bobbing due to combined phenothiazine and benzodiazepine poisoning. J Neurol Neurosurg Psychiatry 1993;56:1136–7. 3 Rottach KG, Wohlgemuth WA, Dzaja AE, et al. Effects of intravenous opioids on eye movements in humans: possible mechanisms. J Neurol 2002;249:1200–5. Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow Video 1 (a) The eyes exhibited conjugate upward movement, followed by a brief tonic phase and rapid downward movement to the primary position. These cycles were repeated at irregular intervals. (b) Ocular dipping was resolved after withdrawal of droperidol and fentanyl. Kitagawa N, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-206951 1 Images in … on 10 July 2021 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Reports: first published as 10.1136/bcr-2014-206951 on 29 September 2014. Downloaded from
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Drug-induced reverse ocular dippingNaoyuki Kitagawa, Michio Sakurai
Department of Neurology,Kohsei Chuo General Hospital,Tokyo, Japan
Correspondence toDr Naoyuki Kitagawa,[email protected]
Accepted 9 September 2014
To cite: Kitagawa N,Sakurai M. BMJ Case RepPublished online: [pleaseinclude Day Month Year]doi:10.1136/bcr-2014-206951
DESCRIPTIONA 19-year-old male patient, who had undergonelaminectomy for lumbar disc herniation the previ-ous day, reported involuntary upward movement ofhis eyes. The eyes exhibited conjugate upwardmovement, followed by a brief tonic phase, andrapid downward movement to the primary pos-ition. These cycles were repeated at irregular inter-vals (video 1). He was awake and could respond tosimple commands and explain his symptoms in hisown words. There were no neurological abnormal-ities except abnormal eye movement. After thesurgery, droperidol and fentanyl had been adminis-tered by continuous infusion for pain relief. Theabnormal eye movements resolved within 2–3 hafter withdrawal of these drugs (video 1). Brain CTand blood examination revealed no abnormalities.Ocular bobbing is the best known abnormal
spontaneous eye movement, and several variants ofthese movements have been described according tothe direction and speed of the drifts. Reverseocular dipping is one of these variants, firstdescribed by Mehler.1 Abnormal spontaneous eyemovements have been shown to be associated withvarious clinical settings and a few cases of
drug-induced abnormal eye movement have beenreported.1 2 It has been reported that fentanyl cancause transient disturbance of eye fixation withdownbeat nystagmus in normal patients.3 Opioidreceptors are located in the medial vestibularnucleus. The activation of opioid receptors in themedial vestibular nucleus inhibits the tonic dis-charge of these cells, which may cause eye fixationabnormalities.3 In our case, fentanyl may haveinduced reverse ocular dipping by a similarmechanism.
Learning points
▸ Reverse ocular dipping is a rare abnormal eyemovement, which could be caused by somedrugs.
▸ Opioid may cause eye fixation abnormalitiesand it could induce reverse ocular dipping.
Contributors NK and MS contributed in the drafting/revising themanuscript, study concept or design, analysis or interpretation ofdata and gave final approval. MS was involved in the acquisition ofdata.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peerreviewed.
REFERENCES1 Mehler MF. The clinical spectrum of ocular bobbing and ocular
dipping. J Neurol Neurosurg Psychiatry 1988;51:725–7.2 Lennox G. Reverse ocular bobbing due to combined phenothiazine
and benzodiazepine poisoning. J Neurol Neurosurg Psychiatry1993;56:1136–7.
3 Rottach KG, Wohlgemuth WA, Dzaja AE, et al. Effects ofintravenous opioids on eye movements in humans: possiblemechanisms. J Neurol 2002;249:1200–5.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visithttp://group.bmj.com/group/rights-licensing/permissions.BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:▸ Submit as many cases as you like▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles▸ Access all the published articles▸ Re-use any of the published material for personal use and teaching without further permission
For information on Institutional Fellowships contact [email protected]
Visit casereports.bmj.com for more articles like this and to become a Fellow
Video 1 (a) The eyes exhibited conjugate upwardmovement, followed by a brief tonic phase and rapiddownward movement to the primary position. Thesecycles were repeated at irregular intervals. (b) Oculardipping was resolved after withdrawal of droperidol andfentanyl.
Kitagawa N, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-206951 1
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on 10 July 2021 by guest. Protected by copyright.
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ase Reports: first published as 10.1136/bcr-2014-206951 on 29 S
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Drug-induced reverse ocular dippingDescriptionReferences
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