Paraneoplastic Opsoclonus/Flutter

Opsoclonus; Ocular FlutterOscillopsiaIn 1975 this patient presented with oscillopsia due to opsoclonus with ocular flutter. Opsoclonus with flutter is a paraneoplastic syndrome associated with occult cancer of the breast, ovary and lung. This patient had cancer of the breast. In 1954 Cogan first used the term "ocular flutter" to describe a rare disorder of horizontal eye movements characterized by rapid bursts of synchronous back-to-back horizontal oscillatory movements usually seen in the primary position of gaze. Since then, there have been over 50 reports, usually single cases or small series, linking the phenomenon to a wide variety of brainstem and cerebellar conditions, e.g. post enteroviral infection, cerebral malaria, cyclosporine treatment and meningitis, but perhaps most frequently associated with parainfectious states or, with opsoclonus, as a paraneoplastic manifestation of occult malignancy. In 1986, a patient of mine presented with opsoclonus as a manifestation of occult adenocarcinoma of the breast. Her cerebrospinal fluid and blood were found to contain an anti-neuronal antibody which was named after her, using the first two initials of her surname, the Anti Ri antibody. Anti-Ri Antibody: The index case ID931-1 is in this collection. Review this case alongside the current case for additional information.This patient with paraneoplastic opsoclonus/flutter has: • Continuous, spontaneous, rapid multidirectional conjugate saccades characteristic of opsoclonus. • These oscillations persist under closed eyelids and during sleep. • In addition she has ocular flutter seen here as horizontal back-to-back saccades without an inter- saccadic interval.Review ID166-2 No imaging studies are available in this patient.Review ID166-2Breast adenocarcinomaTable 10-8 Etiology of Ocular Flutter and Opsoclonus. Pg 525 (6)1. Averbuch-Heller L, Remler B. Opsoclonus. Semin Neurol 1996;16 (1):21-26. http://www.ncbi.nlm.nih.gov/pubmed/8879053 2. Budde-Steffen C, Anderson NE, Rosenblum MK, Graus F, Ford D, Synek, BJL, Wray, SH, Posner JB. An anti-neuronal autoantibody in paraneoplastic opsoclonus. Ann Neurol 1988;23:528-531. http://www.ncbi.nlm.nih.gov/pubmed/3389761 3. Buttner U. Straube A, Handke V. Opsoclonus and ocular flutter. Nervenarzt 1997;68:633-637. http://www.ncbi.nlm.nih.gov/pubmed/9380208 4. Cogan DG. Ocular dysmetria: flutter like oscillations of the eyes, and opsoclonus. Arch Ophthalmol 1954;51:318-335. http://www.ncbi.nlm.nih.gov/pubmed/13123617 5. Helmchen C, Rambold H, Sprenger A, Erdmann C, Binkofski F. Cerebellar activation in opsoclonus: An fMRI study. Neurology 2003;61:412-415. http://www.ncbi.nlm.nih.gov/pubmed/12913213 6. Leigh RJ, Zee DS. Diagnosis of Nystagmus and Saccadic Intrusion. Chp 10:475-558. In: The Neurology of Eye Movements, Fourth Edition. Oxford University Press, NY. 2006. 7. Luque AF. Furneaux HM, Ferziger R, Rosenblum MK, Wray SH, Schold SC Jr, Glantz MJ, Jaeckle KA, Biran H, Lesser MK, Paulsen WA, River ME, Posner JH. Anti-Ri: an antibody associated with paraneoplastic opsoclonus and breast cancer. Ann Neurol 1991;29:241-251. http://www.ncbi.nlm.nih.gov/pubmed/2042940 8. Shams'ili S, Grefkens J, de Leeuw, B, van den Bent M, Hooijkaas H, van der Holt, Bronno, Vecht C, and Smitt, PS. Paraneoplastic cerebellar degeneration associated with antineuronal antibodies: analysis of 50 patients. Brain 2003; 126(6):1409-1418. http://www.ncbi.nlm.nih.gov/pubmed/12764061 9. Wong AM, Musallam S, Tomlinson RD, Shannon P, Sharpe JA. Opsoclonus in three dimensions: oculographic, neuropathologic and modeling correlates. J Neurol Sci 2001;189:71-81. http://www.ncbi.nlm.nih.gov/pubmed/1153523