Abnormal eye movements without visual symptoms


Abnormal eye movements without visual symptoms may be caused by disease of the:

  • eye/s

  • extraocular muscles

  • brain

Occasionally, a patient will be referred to you because although he or she is visually asymptomatic (or has had long-standing poor vision in one or both eyes), the eyes have been observed to move in an abnormal fashion. The abnormal eye movements are often observed during an examination by a doctor for another problem (e.g. for headaches) or during a routine eye examination. These incidentally noticed abnormal movements include:

  • misaligned eyes without diplopia, e.g. long-standing strabismus since childhood

  • abnormal voluntary eye movements without diplopia, e.g. diffuse external ophthalmoplegia or gaze palsy

  • repetitive involuntary eye movements without oscillopsia, e.g. congenital idiopathic nystagmus.

As ophthalmologists, we need to know that although most asymptomatic eye movement disorders are benign, they can rarely be the first sign of serious disease. For example, vertical saccadic palsy may be an early sign of progressive supranuclear palsy (PSP) and horizontal gaze palsy may be the presenting sign of a brainstem tumor. In most cases of brain disease, however, other neurologic symptoms and/or signs are present.

If the patient has a known history of a very long-standing problem that has previously been appropriately investigated (e.g. congenital idiopathic nystagmus), then nothing further needs to be done. However, if there is any doubt regarding the nature of the eye movement disorder, the patient should be evaluated by a neuro-ophthalmologist.

Examination checklist

Abnormal eye movements without visual symptoms

Have you asked about, and looked for, all the following key features?


  • how was the abnormal movement noticed?

    • on a routine check or was the patient having visual or neurologic symptoms?

    • when was the abnormal movement first noticed?

    • any previous investigation or treatment?

  • previous ophthalmic history: childhood strabismus, poor vision, patching?

  • any neurologic symptoms: headache, problems with memory, walking, talking?

  • previous medical and surgical history

    • medications, present or past

    • social history: alcohol, illicit drugs

  • system review questions: any clues to the cause anywhere in the body?


  • visual acuity

  • visual field testing to confrontation

  • eye movement testing

    • are the eyes aligned in primary position?

    • nature of the abnormal movement in primary position

    • does the abnormal movement change in other positions of gaze?

    • smooth pursuit testing of range of eye movement

    • saccades: horizontal, then vertical

    • convergence

    • vestibulo-ocular reflex (VOR, “doll’s-head”)

  • pupils

    • relative afferent pupillary defect (RAPD)?

    • anisocoria?

  • eyelids: ptosis?

  • orbits

  • decreased corneal or facial sensation to light touch?

  • orbicularis or facial weakness?

  • full neurologic examination: if the patient has neurologic symptoms

Plus: perform perimetry if:

  • field defect to confrontation, or

  • decreased visual acuity, color acuity or RAPD

Misaligned eyes without diplopia

Poor vision or childhood-onset strabismus

  • a misaligned eye may be the cause of poor vision (strabismic amblyopia) or poor vision may be the cause of a misaligned eye (“sensory” esotropia or exotropia)

  • strabismic amblyopia: an eye that is constantly misaligned (usually turned in) in early life will often result in poor vision in the turned eye (“lazy eye”)

  • “sensory” deviations: blind eyes tend to turn:

    • in in children (“sensory” esotropia)

    • out in adults (“sensory” exotropia)

  • in all these deviations, there should be no visible restriction of movement of either eye and the deviation should measure the same in all directions of gaze (i.e. the strabismus is “comitant”) ( Fig. 8.1 )

    • the exception to this is Duane syndrome (the patient is often a child or young adult referred with incidentally noticed “sixth nerve palsy” with no diplopia)


    This woman has had a long-standing, asymptomatic, left esotropia since childhood. Note that the eye movements are full and the angle of deviation is the same in all positions of gaze. A, Right gaze. B, Primary position. C, Left gaze.

  • treatment

    • surgical treatment is indicated in an adult or older child if the patient is distressed by the appearance of the eyes

    • however, beware of postoperative diplopia (that can occur even if the vision is poor in one or both eyes); a neuro-ophthalmologist or strabismologist should perform careful preoperative diplopia testing before any surgery is contemplated

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Jun 25, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Abnormal eye movements without visual symptoms

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