What is nystagmus in multiple sclerosis (MS)?

Updated: Feb 21, 2019
  • Author: Fiona Costello, MD, FRCP; Chief Editor: Hampton Roy, Sr, MD  more...
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Nystagmus is common in MS, affecting up to 30% of patients. [49] Common mechanisms that contribute toward the development of nystagmus include impaired fixation, vestibular imbalance, and abnormal gaze-holding. [49] Recognizing patterns of nystagmus can be useful in localizing lesions in patients with MS. Unfortunately, although much is known about the anatomy, physiology, and pharmacology of the ocular motor system, therapeutic options for nystagmus remain somewhat limited. Most reports of putative therapies have been based on a small number of subjects, and not all patients always respond positively to the treatment. [41]

Table 4. Patterns of Nystagmus in Multiple Sclerosis (Open Table in a new window)

Type of Nystagmus

Clinical Features

Anatomical Site


Gazeevoked nystagmus

Slow drift of eyes away from target followed by a corrective saccade (jerk) in the direction of eccentric gaze [49]

Lesions in the brainstem or cerebellum that impair neural integrator function [49]


Pendular nystagmus

Horizontal, vertical, or mixed components in one or both eyes with a back-and-forth slow phase without a corrective saccade (jerk)

Brainstem or cerebellar lesions which damage neural integrator function [49]

Gabapentin (100 – 400 po tid); memantine (15-60mg per day); clonazepam (0.5-1mg tid) [40, 49]

Downbeat nystagmus

Tonic upward deviation of the eyes followed by a fast downward saccade; may increase with downgaze and lateral gaze [40, 41]

Lesion of the cervicomedullary junction or cerebellum that disrupt input from the posterior semicircular canals [40]

Clonazepam 0.5 mg tid; baclofen 10 mg tid; gabapentin; 3,4-diaminopyridine 20 mg tid; 4-aminopyridine 10 mg tid; base down prisms [41]

Upbeat nystagmus

A downward drift of the eyes is followed by an upward saccade; usually increases on up gaze. Vertical smooth pursuit is usually disrupted by the nystagmus. [40, 41]

Pontomedullary or pontomesencephalic lesions of the ventral tegmental tract that disrupt projections from the anterior semicircular canals [41]

Baclofen 5-10 mg tid 4-aminopyridine 10 mg tid [41]

Periodic alternating nystagmus

A spontaneous horizontal beating nystagmus, the direction of which changes periodically. Periods of oscillation range from 1 second to 4 minutes (typically 1-2 minutes). [41]

Vestibulocerebellar damage; lesions of the inferior cerebellar vermis that affect velocity storage mechanisms and the stability of the vestibulo-ocular reflex [41]

Baclofen 5-10 mg tid, phenothiazine, barbiturates, and memantine [41]

Seesaw nystagmus

A pendular or jerk oscillation characterized by an intorsion and elevation of one eye and a corresponding extorsion and depression of the other; during the next half-cycle, the torsional and vertical movements reverse [41]

Unilateral mesodiencephalic lesions that affect the interstitial nucleus of Cajal and vestibular afferents from the vertical semicircular canals (jerk hemi-seesaw); the pendular form of seesaw nystagmus is associated with lesions affecting the optic chiasm [41]

Clonazepam and gabapentin [41]

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