The Canadian Movement Disorder Group
Oculogyric Crisis

An Oculogyric Crisis (OGC) usually occurs as a side effect of neuroleptic drug treatment.  It is one of the acute dystonic reactions. It is the most common of the ocular dystonic reactions (which include blepharospasm, periorbital twitches, and protracted staring episodes). Of those patients with dystonic reactions, OGC makes up 6%. The clinical spectrum though is poorly understood, leading to the frequent mislabel of a functional disorder.

Alcohol, emotional stress, fatigue, as well as suggestion have all been  identified as being able to precipitate OGC attacks in susceptible individuals. The onset of a crisis may be paroxysmal or stuttering over several hours.

Initial symptoms include restlessness, agitation, malaise, or a fixed stare  followed by the more characteristically described maximal upward deviation of the eyes in the sustained fashion. The eyes may also converge, deviate upward and laterally, or deviate downward. The most frequently reported associated findings are backwards and lateral flexion of the neck, widely opened mouth, tongue protrusion, and ocular pain. A wave of exhaustion follows some episodes. The abrupt termination of the psychiatric symptoms at the conclusion of the crisis is most striking.

Other features that are noted during attacks include mutism, palilalia, eye blinking, lacrimation, pupil dilation, drooling, respiratory dyskinesia,  increased BP and heart rate, facial flushing, headache, vertigo, anxiety, agitation, compulsive thinking, paranoia, depression, recurrent fixed ideas, depersonalization, violence, and obscene language.

Causes or triggering factors in OGC include: neuroleptics, amantadine, benzodiazepines, carbamazepine, chloroquine, cisplatin, diazoxide, influenza vaccine, levodopa, lithium, metoclopramide, nifedipine, pemoline,  phencyclidine, reserpine, tricyclics, postencephalitic Parkinson's, Tourette's syndrome, multiple sclerosis, neurosyphilis, head trauma, bilateral thalamic infarction, lesions of the fourth ventricle, cystic glioma of the 3rd ventricle, herpes encephalitis, and juvenile Parkinson's.

It is often not realized that in addition to the acute presentation, OGC can develop as a recurrent syndrome, triggered by stress, and exposure to the above drugs.

Treatment in the acute phase involves reassurance and treatment with Cogentin ( IV or MI)  and/or Benadryl (diphenhydramine) and/or Diazepam or lorazepam. Maintenance therapy with oral forms of the above medications or amantadine  are indicated in more chronic recurrent cases.

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