Oculogyric crisis: the girl who stared at the ceiling

Patients are aware of these movements, and frequently report associated discomfort.1 2 There may also be neck dystonia, tongue protrusion, blepharospasm, autonomic signs and psychiatric symptoms such as anxiety.1 Oculogyric crisis can develop in various genetic, metabolic and degenerative neurologic...

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Published inPractical neurology Vol. 23; no. 4; pp. 348 - 349
Main Authors Oliveira, Daniela Santos, Grebe, Hans Peter
Format Journal Article
LanguageEnglish
Published England BMJ Publishing Group Ltd 01.08.2023
BMJ Publishing Group LTD
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Summary:Patients are aware of these movements, and frequently report associated discomfort.1 2 There may also be neck dystonia, tongue protrusion, blepharospasm, autonomic signs and psychiatric symptoms such as anxiety.1 Oculogyric crisis can develop in various genetic, metabolic and degenerative neurological disorders, some brain lesions, and as an adverse effect of medication, namely antipsychotics and antiemetics.1 The incidence of iatrogenic oculogyric crisis is currently unknown, being estimated in 0.9%–6.8% for antipsychotics1 3 and 1 in 500 for metoclopramide.4 Risk factors include male gender, young age, recent cocaine use, greater severity of illness and baseline psychopathology; use of high potency neuroleptics (especially at high doses given parenterally), abruptly stopping anticholinergics within the first few weeks of starting neuroleptics, metabolic conditions and family history of dystonia.1 3 The diagnosis is clinical, based on history particularly recently administered medications, and neurological examination to exclude signs of other acute conditions.1 3 The exact pathogenesis of oculogyric crisis is uncertain, but probably relates to a dopaminergic–cholinergic imbalance in the basal ganglia, namely an hypodopaminergic state and striatal cholinergic hyperactivity.1–3 Therefore anticholinergics and dopamine agonists act as a treatment and supportive diagnostic criterion.1 First-line treatment is with anticholinergics; the exact drug used varies by country, and includes procyclidine—given intravenously in acute oculogyric crisis—biperiden, benztropine (neither available in UK) and trihexyphenidyl. Alternatives include antihistamines (eg, chlorpheniramine and diphenhydramine) and benzodiazepines (eg, clonazepam).1–3 Supportive measures should be provided immediately if indicated.3 In drug-induced oculogyric crisis, the dose should be reduced or stopped.1 3 To avoid recurrence, one should continue the management of oculogyric crisis for at least a week, though it may take longer in tardive oculogyric crisis.1 2 Key point Oculogyric crisis can be triggered by metoclopramide. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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ISSN:1474-7758
1474-7766
DOI:10.1136/pn-2022-003653