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OCULOGYRIC CRISIS

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					OCULOGYRIC CRISIS
         Onuma, Kalu MD
                  PGY 4
         CASE PRESENTATION
 IDENTIFYING PROFILE.




 25 years old married Caucasian female who lives with
  her husband and their 5 years old son and 3 years old
  daughter in Kingsport, TN
CLINICAL PRESENTATION
 Sustained upward deviation of eyes.
 Mutism
 Restlessness
 Agitation
 Behavioral disturbance.
 Pupil dilation
 Backward flexion of neck.
                       HPI
 Patient had been in apparent good health until the
  death of her father in law, from which time she
  became increasingly depressed, not eating and
  sleeping well.

 Was subsequently admitted to psych hospital to
  address worsening psychosis and mood symptoms.

 Was rushed to the ER for evaluation and treatment of
  sudden onset of AMS after 48 hours of hospitalization
  in the psych facility for Psychosis NOS.
 MEDICATION HISTORY.
   Ambien orally 10mg QHS, Ativan taper.
   Abilify PO 5mg x 1
   Geodon IM 10mg bid(
   Haldol IM 5mg q8hours prn(
   Thorazine IM 25mg x 1


 PAST PSYCHIATRY HISTORY.
   Significant for polysubstance abuse.(THC, Opiates, Benzos)
   Nil previous psych hospitalization.

 PAST MEDICAL HISTORY.
    None

 LABS/IMAGING STUDIES.
    CMP, CBC, CT, MRI, HIV, CRP, Ammonia levels
    Vit B12, Ceruloplasmin, EEG.
      DIAGNOSIS/TREATMENT
 OCULOGYRIC CRISIS




 IM Benadryl.
          PATHOGENESIS
 MIDBRAIN PATHWAYS
    -Substantia nigra pars reticula---Superior Colliculi
   -Substantia nigra pars compacta--Reticular
formation



 BASAL GANGLIA
   -subcortical component
    of family of circuits{Oculomotor, Limbic, Prefrontal
                          Skeletal motor circuits}
                       CAUSES
 MEDICATIONS
       -Neuroleptics, Metoclopramide.
       -Carbamazepine, lithium, PCP
       -Levodopa, Amantadine, Chloroquine

 BRAIN STEM LESION
          -Ischemic, Neoplastic, or Inflammatory.

 HEAD TRAUMA

 INFECTIONS
        -Neurosyphylis, and Herpes Encephalitis.

 OTHERS.
      -Alcohol, Emotional stress, and fatigue
      -Inherited errors of metabolism
       CLINICAL FEATURES
 Involuntary, sustained deviation of the eyes.
          CLINICAL FEATURES
 Involuntary, sustained deviation of the eyes.

 Mutism, eye blinking, and pupil dilation.

 Flexion of the neck.

 Restlessness, Agitation, and Behavioral disturbances.

 Transient psychotic episodes.
              -Visual hallucination.
              -Auditory hallucination.

 Autonomic dysfunction.
                RISK FACTORS
 Male gender

 Young age.

 High doses

 High-potency antipsychotics

 History of substance abuse(alcohol, and or cocaine)

 Genetic susceptibility(Slow metabolizers)

 Comorbid conditions(Tourette & Parkinsonism)
     PATIENT ASSESSMENT
 Physical status.
      -safety of patient and staff.
     -history/collateral information.
     -careful review of medications .
     -review of medical records.
     -physical and neurological examination.



 Mental status examination.
    DIAGNOSTIC STUDIES
 CBC
 CMP
 UDS
 VDRL
 CT
 MRI
 EEG
 EKG
 URINALYSIS
      DIFFERENTIAL DIAGNOSIS
 Seizure Disorder.

 Delirium.

 Other EPS.
     -Tardive, Parkinsonism, Akathisia

 CNS lesion(focal basal ganglia or Thalamus).

 Postencephalic parkinsonism.

 Tyrosine hydroxylase deficiency.
 TREATMENT/MANAGEMENT
 Pharmacologic Intervention
    -Anticholinergic medication
          (Benadryl or Cogentin)



 Environmental manipulation.
     -Place patient in a room near nursing station.
     -Orient patient repetitively.
     -Use sitter.
     - Use restraints when less restrictive measures have failed.


      -
COURSE(PROGNOSIS)
 Typical course usually ranges from 24-48 hours.
       -upon medication withdrawal or reduction.

 Symptom relief within minutes with anticholinergics.

 Recurrent crisis maybe observed on med re-exposure.

 Excellent prognosis.
THANK YOU!
 Questions ?




 Contributions……




 References will be made available on request.
   Contact: onuma@mail.etsu.edu

				
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