Objective: To describe a case of ocular flutter occurring as part of alcohol withdrawal syndrome.

Background: Ocular flutter is a form of saccadic oscillation consisting of back to back horizontal saccades. It is considered to be a subtype of opsoclonus and is commonly associated with paraneoplastic syndrome, metabolic derangement and encephalitis. We present a case of alcohol withdrawal which is followed by ocular flutter, and alcoholic tremor. To the best of our knowledge this has not been reported.

Results: 32 year old male with history of alcoholism was found down by bystanders. The patient went through alcohol withdrawal while in the hospital, being slightly confused. According to witnesses he was interactive, talking, eating and walking. Four days later he had generalized seizures. He required life support and sedation. He developed ocular flutter and severe coarse tremor in bilateral upper extremities. The tremor improved with a residual postural tremor while his ocular flutter remained unchanged. Paraneoplastic and imaging studies ruled out malignancy. CSF was negative for encephalitis. Additionally, GQ1b ab and anti-GAD antibodies were negative. Brain imaging revealed mild cerebral and cerebellar atrophy. There were no signs of Wernicke’s encephalopathy.

Conclusions: Our patient appeared to have alcohol withdrawal with seizures, followed by ocular flutter and tremor. The tremor improved over time with abstinence from alcohol. This is consistent with alcoholic tremor which is distal, coarse, irregular, rapid and worse with movement. However the ocular flutter persisted and was symptomatic with oscillopsia. Ocular flutter is uncommon and has not been reported in association with alcohol withdrawal. Usually, adult onset ocular flutter resolves spontaneously or with treatment of the underlying neoplasm. Abstinence from alcohol did not appear to influence it at three months, however may continue to improve over time. Ocular flutter is thought to be generated in either the brainstem or in the cerebellum. Abnormal Purkinje cell activity in the cerebellum leads to reduced inhibition on the fastigial nucleus, which results in a loss of omnipause neuron inhibition on burst neurons within the paramedian pontine reticular formation. We feel in this case the cerebellum is implicated due to the underlying alcohol abuse. It is possible that alcohol cerebellar degeneration resulting in abnormal Purkinje cell activity may trigger the ocular flutter.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/ocular-flutter-in-alcohol-withdrawal-syndrome/