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      Ein Fall von Skew Deviation und Downbeat-Nystagmus infolge von Lithium-Toxizität

      a , a , b , *
      Karger Kompass Ophthalmologie
      S. Karger AG
      Lithium, Nystagmus, Skew Deviation

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          Hintergrund: Lithium-Salze finden häufige Anwendung als Prophylaxe oder Behandlung bei bipolaren Störungen und haben zahlreiche Nebenwirkungen. Allerdings gibt es keine Berichte über Skew Deviation und Downbeat-Nystagmus im Zusammenhang mit Lithium. Wir beschreiben hier den ersten Fall von Lithium-induzierter Skew Deviation und Downbeat-Nystagmus. Vorstellung des Falls: Eine 39 Jahre alte Frau stellte sich mit seit 1–2 Monaten bestehender intermittierender vertikaler Diplopie und Schwindelgefühl vor. Die ophthalmologische Untersuchung ergab einen Downbeat-Nystagmus und eine Hypertropie von 6 Prismen-Dioptrien rechts. Die Fundoskopie zeigte eine leichte Inzyklotorsion des rechten Auges. Allerdings waren Duktionen und Versionen im Normbereich. Die übrigen neurologischen Untersuchungen waren ebenfalls ohne Befund. Die Frau hatte eine bipolare Störung, die seit 6 Jahren mit 600–900 mg Lithium pro Tag behandelt wurde. Zwei Monate bevor sie sich zum ersten Mal bei uns vorstellte, war die Lithium-Tagesdosis auf 1200 mg erhöht worden. Wir überwiesen die Patientin an einen Psychiater. Trotz eines Lithium-Serumspiegels im normalen therapeutischen Bereich wurde die Lithium-Tagesdosis der Patientin zunächst auf 600 mg reduziert und Lithium danach abgesetzt. Sechs Tage nach Absetzen von Lithium waren der Downbeat-Nystagmus und die rechtsseitige Hypertropie der Patientin vollständig abgeklungen und die Symptome traten über den Zeitraum von 1 Jahr nicht wieder auf. Schlussfolgerung: Auch wenn die Serumspiegel im normalen therapeutischen Bereich liegen, können als Nebenwirkung von Lithium Downbeat-Nystagmus und Skew Deviation auftreten. Eine Dehydratation kann zur Neurotoxizität von Lithium beitragen.

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          Most cited references18

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          Lithium side effects and toxicity: prevalence and management strategies

          Despite its virtually universal acceptance as the gold standard in treating bipolar disorder, prescription rates for lithium have been decreasing recently. Although this observation is multifactorial, one obvious potential contributor is the side effect and toxicity burden associated with lithium. Additionally, side effect concerns assuredly play some role in lithium nonadherence. This paper summarizes the knowledge base on side effects and toxicity and suggests optimal management of these problems. Thirst and excessive urination, nausea and diarrhea and tremor are rather common side effects that are typically no more than annoying even though they are rather prevalent. A simple set of management strategies that involve the timing of the lithium dose, minimizing lithium levels within the therapeutic range and, in some situations, the prescription of side effect antidotes will minimize the side effect burden for patients. In contrast, weight gain and cognitive impairment from lithium tend to be more distressing to patients, more difficult to manage and more likely to be associated with lithium nonadherence. Lithium has adverse effects on the kidneys, thyroid gland and parathyroid glands, necessitating monitoring of these organ functions through periodic blood tests. In most cases, lithium-associated renal effects are relatively mild. A small but measurable percentage of lithium-treated patients will show progressive renal impairment. Infrequently, lithium will need to be discontinued because of the progressive renal insufficiency. Lithium-induced hypothyroidism is relatively common but easily diagnosed and treated. Hyperparathyroidism from lithium is a relatively more recently recognized phenomenon.
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            Skew deviation with ocular torsion: a vestibular brainstem sign of topographic diagnostic value.

            Fifty-six patients with unilateral brainstem infarctions presenting with skew deviation of the eyes were analyzed for static vestibular function in the roll plane. Ischemic lesions were allocated to the level and side of the brainstem by the clinical syndrome and neuroimaging. Two findings of clinical relevance were obtained: (1) All skew deviations were ipsiversive (ipsilateral eye was undermost) with caudal pontomedullary lesions and contraversive (contralateral eye was lowermost) with rostral pontomesencephalic lesions. (2) All skew deviations were associated with concomitant ocular torsion and tilts of subjective visual vertical toward the undermost eye. Thus, skew deviation or more correctly, ocular skew torsion is a sensitive brainstem sign of localizing and lateralizing value. Evidence is presented that the ocular skew torsion sign indicates a vestibular tone imbalance in the roll plane secondary to graviceptive pathway lesions.
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              Treatment of lithium intoxication: facing the need for evidence

              Lithium has been used as the gold standard in the treatment of major depressive and bipolar disorders for decades. Due to its narrow therapeutic index, lithium toxicity is a common clinical problem. Although risk factors for lithium intoxication seem to be well-described, lacking patient education and inexperience of treatment are assumed to contribute to the probability of lithium intoxication. A review of literature shows that the treatment of lithium intoxication has not been adequately studied or standardized. The aim of this literature review is to compile and present current evidence on the treatment of lithium intoxication and contribute to a standardization regarding general treatment recommendations as well as evidence on indication for extracorporeal methods. Against the background of this common and potentially life-threatening condition, the standardization of the treatment of lithium intoxication is definitely a task for the future.

                Author and article information

                Karger Kompass Ophthalmologie
                S. Karger AG
                November 2020
                26 October 2020
                : 6
                : 4
                : 208-211
                [_a] aDepartment of Ophthalmology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Republik Korea
                [_b] bDepartment of Ophthalmology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Republik Korea
                Author notes
                *In Jeong Lyu, Department of Ophthalmology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, #75 Nowon-ro, Nowon-gu, Seoul, Republik Korea 01812, joen03@hanmail.net
                512225 Kompass Ophthalmol 2020;6:208–210
                © 2020 S. Karger GmbH, Freiburg

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                Page count
                Figures: 2, Pages: 4
                Erfahrung aus der Praxis

                Vision sciences,Ophthalmology & Optometry,Pathology
                Nystagmus,Skew Deviation,Lithium
                Vision sciences, Ophthalmology & Optometry, Pathology
                Nystagmus, Skew Deviation, Lithium


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