Oculogyric crisis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Overview

Oculogyric crisis (OGC) is the name of a dystonic reaction to certain drugs and/or medical conditions. The term "Oculogyric" refers to rotating of eyeballs, but several other responses are associated with the crisis.

Causes

Drugs that can trigger an oculogyric crisis include neuroleptics, amantadine, benzodiazepines, carbamazepine, chloroquine, cisplatin, diazoxide, influenza vaccine, levodopa, lithium, metoclopramide, nifedipine, pemoline, phencyclidine, Perphenazine, reserpine, and tricyclics.

Other causes can include postencephalitic Parkinson's, Tourette's syndrome, multiple sclerosis, neurosyphilis, head trauma, bilateral thalamic infarction, lesions of the fourth ventricle, cystic glioma of the third ventricle, herpes encephalitis, and juvenile Parkinson's.

Symptoms and signs

Initial symptoms include incredible restlessness, agitation, malaise, or a fixed stare. Then comes the more characteristically described extreme and sustained upward deviation of the eyes. In addition, the eyes may 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. However it may also be associated with intensely painful jaw spasm which may result in the breaking of a tooth. A wave of exhaustion may follow an episode. 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 blood pressure and heart rate, facial flushing, headache, vertigo, anxiety, agitation, compulsive thinking, paranoia, depression, recurrent fixed ideas, depersonalization, violence, and obscene language.

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.

Causes

Life Threatening Causes

• Bilateral thalamic infarction
• Bilateral thalamic lesion
• Head trauma
• Herpes encephalitis
• Multiple sclerosis
• Tertiary syphilis
• Parkinson's disease

Common Causes

• Bilateral thalamic infarction
• Bilateral thalamic lesion
• Gilles de la tourette syndrome
• Herpes encephalitis
• Juvenile parkinson's
• Kernicterus 
• Multiple sclerosis
• Neuroleptics
• Neurosyphilis
• Parkinson disease
• Postencephalitic parkinson's
• Tourette's syndrome

Causes by Organ System

Cardiovascular	Cystic glioma of the third ventricle, Lesions of the fourth ventricle
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Oxcarbazepine, Promethazine, Carbamazepine, Cetirizine, Chloroquine, Chlorpromazine, Cisplatin, Diazoxide, Domperidone, Fluphenazine, Haloperidol, Levodopa, Lithium, Metoclopramide, Neuroleptics, Nifedipine, Olanzapine, Pemoline, Phencyclidine, Reserpine, Sepiapterin reductase deficiency
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	Tubb4a-related leukodystrophy
Iatrogenic	No underlying causes
Infectious Disease	Herpes encephalitis, Influenza vaccine, Neurosyphilis, Tertiary syphilis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Bilateral thalamic infarction, Bilateral thalamic lesion, Gilles de la tourette syndrome, Herpes encephalitis, Juvenile parkinson's, Kernicterus , Multiple sclerosis, Neuroleptics, Neurosyphilis, Parkinson disease, Postencephalitic parkinson's, Tourette's syndrome
Nutritional / Metabolic	No underlying causes
Oncologic	Cystic glioma of the third ventricle
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	Tertiary syphilis
Trauma	Head trauma
Urologic	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

• Bilateral thalamic infarction
• Bilateral thalamic lesion
• Carbamazepine
• Cetirizine
• Chloroquine
• Chlorpromazine
• Cisplatin
• Cystic glioma of the third ventricle
• Diazoxide
• Domperidone
• Fluphenazine
• Gilles de la tourette syndrome
• Haloperidol
• Head trauma
• Herpes encephalitis
• Influenza vaccine
• Juvenile parkinson's
• Kernicterus 
• Lesions of the fourth ventricle
• Levodopa
• Lithium
• Metoclopramide
• Multiple sclerosis
• Neuroleptics
• Neurosyphilis
• Nifedipine
• Olanzapine
• Parkinson disease
• Pemoline
• Phencyclidine
• Postencephalitic parkinson's
• Reserpine
• Sepiapterin reductase deficiency
• Tertiary syphilis
• Tourette's syndrome
• Tubb4a-related leukodystrophy

Treatment

Immediate treatment of drug induced OGC can be achieved with intravenous antimuscarinic benztropine or procyclidine; which usually are effective within 5 minutes, although may take as long as 30 minutes for full effect. Further doses of procyclidine may be needed after 20 minutes. Any causative new medication should be discontinued.