Oculogyric crisis

General information

• Form of acute dystonia with characteristic tendency of the eyes to deviate
• May occur as an acute or tardive reaction to neuroleptic exposure
• Incidence may be as high as 10% among patients chronically treated with neuroleptics
• Drugs known to trigger oculogyric crises are tetrabenazine, gabapentin, domperidone, carbamazepine, lamotrigine, cetirizine, imipramine and lithium carbonate
• May be associated with structural brain lesions (bilateral paramedian thalamic infarction, midbrain lesion, herpes encephalitis, glioma of the 3rd ventricle and Wilson’s disease
• May occur in patients with dopa-responsive dystonia, in which, treatment with levodopa can terminate the crises
• Ocular deviation is only part of the syndrome
• Opisthotonus, generalized rigidity, intense terror or rage, thalamic pain, autonomic symptoms, hypervigilance, akathisia, forced gasping, complex reiterative movements, pallilalia and catalepsy are among the multitude of accompanying symptoms and signs that have beed described

Management

• Acute dystonia is much easier to treat than tardive phenomena
• IV anticholinergics or antihistamines (eg 25-50 mg IV diphenhydramine) abort an acute dystonia within minutes
• Propranolol or benzodiazepines can be used to control akathisia until the dystonia subsides
• Clonazepam (IV or oral) may be effective in patients with chronic neuroleptic-induced oculogyric crises that do not respond to anticholinergics and antihistamines
• Monamine-depleting agents (reserpine, tetrabenazine) are the most effective agents but have more serious side effects
• Botulinum toxin can be used in selected patients