A 41-year-old man with MS (Figure) experienced debilitating oscillopsia secondary to acquired pendular nystagmus (APN). Treatment with gabapentin and memantine (used individually and then in combination) were mildly effective, but he reported that the oscillopsia reduced dramatically after alcohol consumption. Given responsiveness to alcohol is a feature of essential tremor, we tried a similar therapeutic approach. Propranolol was ineffective, but topiramate 50 mg twice daily resulted in a dramatic improvement in oscillopsia and APN (Video 1). Gabapentin and memantine are commonly used treatments for APN,1 but understanding specific alleviating factors may shed light on pathophysiology and lead to novel therapeutic strategies.
Sagittal (A and B) and axial (C and D) FLAIR images from the patient's head MRI are shown here, with MS lesions marked with yellow arrows. Multiple lesions were evident throughout the brainstem and cerebellum, including in the paramedian area of the pons (a region potentially implicated in patients with acquired pendular nystagmus).
Video 1
Acquired pendular nystagmus in MS—before and after topiramate. On examination while on treatment with memantine 10 mg 3 times daily and gabapentin 1800 mg 3 times daily, pendular nystagmus in an elliptical pattern was evident. On repeat examination after commencing topiramate (in addition to memantine and gabapentin), there was no nystagmus evident. The patient reported dramatic improvement in his symptoms after reaching a topiramate dose of 50 mg twice daily (4 weeks into treatment) and regained the ability to tolerate and complete focused visual tasks, for example, reading and working on the computer. Treatment with gabapentin was subsequently tapered down from 1800 mg 3 times daily to 600 mg twice daily, without any change in symptoms.Download Supplementary Video 1 via http://dx.doi.org/10.1212/201452_Video_1
Study Funding
The authors report no targeted funding.
Disclosure
The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Whitley Aamodt, MD, MPH.
Teaching slides http://links.lww.com/WNL/C418
- Received May 24, 2022.
- Accepted in final form September 8, 2022.
- © 2022 American Academy of Neurology
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