Execution
- 1Position the patient sitting with eyes visible and removes fixation when equipment is available.
- 2Observe for spontaneous nystagmus in primary gaze.
- 3Ask the patient to look left, right, up, and down without excessive end-range gaze.
- 4Record direction, plane, fatigability, fixation suppression, and whether direction changes with gaze.
- 5Integrate the finding with symptom timing, positional testing, head impulse, and neurological signs.
Positive outcome
Direction-changing gaze-evoked nystagmus, pure vertical nystagmus, pure torsional nystagmus, or nystagmus that does not suppress with fixation is concerning for central pathology. Unidirectional horizontal-torsional nystagmus that follows Alexander's law is more consistent with peripheral vestibular imbalance. Positional nystagmus must be interpreted with the provoking maneuver.
Studies
| Study | Reliability | Sn | Sp | LR+ | LR− |
|---|---|---|---|---|---|
| Kattah et al. (2009) | HINTS component | NA | NA | NA | NA |
| Gottlieb et al. (2023) | Cochrane HINTS review | NA | NA | NA | NA |
CommentNystagmus observation is essential but low value as a stand-alone test because interpretation depends on timing, fixation, gaze position, and accompanying signs. It becomes high value when integrated into a structured acute vestibular syndrome examination such as HINTS. Central patterns require urgent escalation.
Low Clinical Value