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Clinical Summary

Oculogyric crisis (OGC) is the most common of the ocular dystonic reactions. It includes blepharospasm, periorbital twitches, and protracted staring episodes. It usually occurs as a side effect of neuroleptic drug treatment. OGC represents approximately 5% of dystonic reactions. The onset of a crisis may be paroxysmal or stuttering over several hours. Initial symptoms include restlessness, agitation, malaise, or a fixed stare followed by the more characteristically described maximal sustained upward deviation of both eyes. The eyes may also converge, deviate upward and laterally, or deviate downward. The most frequently reported associated findings are backward and lateral flexion of the neck, widely opened mouth, tongue protrusion, and ocular pain. Episodes generally last minutes but can range from seconds to even hours. A wave of exhaustion follows some episodes. Other features noted during attacks include eye blinking, lacrimation, pupil dilation, drooling, facial flushing, vertigo, anxiety, and agitation. Several medications have been associated with the occurrence of OGC: cetirizine, neuroleptics, amantadine, benzodiazepines, carbamazepine, chloroquine, levodopa, lithium, metoclopramide, and nifedipine. Careful history and physical examination should exclude the possibility of focal seizures, meningitis, encephalitis, head injury, conversion reaction, Parinaud syndrome, and other types of movement disorders.

FIGURE 14.129

Oculogyric Crisis. This 6-year-old boy developed extrapyramidal symptoms, including opisthotonos and oculogyric crisis, after his dosage of risperidone was increased. Benadryl 12.5 mg orally given at home resolved the opisthotonos. Persistent oculogyric crisis (upward gaze deviation) and hypertonia resolved completely after Benadryl 25 mg intramuscularly. (Photo contributor: Mark Ralston, MD.)

Management and Disposition

Treatment in the acute phase in children involves reassurance, discontinuation of the causative agent, and diphenhydramine at a dosage of 1.25 mg/kg initially; this may be repeated if there is no effect. For moderate to severe cases, give the initial dose parenterally. Occasionally, doses up to 5 mg/kg are required. Treatment with diphenhydramine should be continued every 6 hours for 4 to 7 days. Benztropine can also be used; however, it is not approved for children below 3 years of age. Close monitoring is important during treatment as dystonic reactions are occasionally accompanied by fluctuations in blood pressure and arrhythmias.

Pearls

  1. The abrupt termination of the symptoms at the conclusion of the crisis or after the use of diphenhydramine is diagnostic and most striking.

  2. In infants presenting with “seizures,” unusual behavior, eye deviation, and a history of reflux treated with metoclopramide, the possibility of OGC should be considered. Although the overall incidence of extrapyramidal effects associated with metoclopramide is 0.2%, pediatric and geriatric patients are affected more commonly, with an incidence as high as 10%. These side effects usually occur within a few days of initiation of the medication and are more common at higher doses.

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