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| CASE REPORT |
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| Year : 1994 | Volume
: 42
| Issue : 4 | Page : 212-213 |
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Ping pong gaze (periodic alternating gaze) : A case report
Madhumati Misra, BD Lenka, Sanatan Rath
Department of Ophthalmology, S.C.B. Medical College Hospital, Cuttack, India
Correspondence Address:
Madhumati Misra
Department of Ophthalmology, S.C.B. Medical College Hospital, Cuttack 753 007
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 10577001 
How to cite this article:
Misra M, Lenka B D, Rath S. Ping pong gaze (periodic alternating gaze) : A case report. Indian J Ophthalmol 1994;42:212-3 |
Ping pong gaze or periodic alternating gaze (PAG) is a very particular abnormal eye movement which is detected occasionally in comatosed patients. [1] PAG is a slow and regular conjugate eye movement that is rigorously horizontal and perfectly pendular [2],[3] Presence of PAG is a clinical indicator of bilateral cortical damage with preserved brain stem function. [1],[2],[3],[4] Subsequent disappearance of PAG in the same patient indicates that irreversible brain stem damage has already occurred. We report the curious appearance and disappearance of this rare oculomotor anomaly in a fatal case of head injury.
| Case report | |  |
A 25-year-old man sustained closed head injury in a vehicular accident and was admitted to the department of neurosurgery. The patient was deeply comatose (Glasgow Coma Scale, GCS 4) on admission. There was decerebrate rigidity without focal paresis and bilateral extensor plantar response. Immediate CT scan of head showed bilateral diffuse hemispheric oedema without focal mass lesion. On conservative treatment, GCS remained between 4 to 6. Neuroophthalmic examination was undertaken for bilateral black eye and subconjunctival haemorrhage.
On examination, both eyes had conjugate mobility disorder, equally reactive pupil, and normal optic fundi. The eyeballs moved from one corner to the other and did not stop in the lateral position; the movements were slow and regular. Pursuit and saccadic movements, and convergence could not be tested because of coma. Cold water irrigation in the ears made the abnormal movement disappear and the eyes stopped in the lateral position. But quickly, the abnormal movement reappeared.
The patient remained in coma for 60 days prior to death. Repeat CT scans showed massive bilateral cortical infarction and secondary brain oedema. The PAG persisted throughout the period of coma and almost disappeared 2 days prior to death.
| Discussion | | |
Ping pong gaze or periodic alternating gaze occurs in comatose patients. The lesion giving rise to PAG is always bilateral, ischemic and extensive infarction. [1],[2],[3],[4] Associated pontine haemorrhage and temporal herniation has also been described [1],[2],[4] PAG has been documented occasionally in patients with mesencephatic herniation, solitary crus cerebri lesions and congenital hydrocephalus .[2],[4]
PAG is caused by liberation of brain stem functions without superior inhibition. [1],[5],[6] Normal results of caloric tests with classically bilateral lesions supported this hypothesis. During sleep spontaneous brain stem activity decreases, which allows the PAG to disappear. [1] This observation supports that PAG is due to brain stem function.
In the previous cases reported in the literature, the duration of abnormal ocular movement was short, extending from few hours to few days [.2],[6] The most reported patients were comatosed due to extensive bilateral hemispheric lesion with initially preserved brain stem function. Most of these patients ultimately died and the PAG curiously disappeared few hours prior to death. This possibly was due to secondary irreversible brain stem damage resulting from ischemia or raised intracranial pressure.
The detection of PAG in a comatosed patient is a clinical indicator of bilateral extensive cortical damage, and hence a poor prognosis. Disappearance of PAG during therapy indicates a grave prognosis and may herald impending death of a comatosed patient.
| References | | |
| 1. | Steward JD, Kirkham T, Mathieson G. Periodic alternating gaze. Neurology 29:222-224, 1979.  |
| 2. | Larmande P, Limodin J, Dongmo L, et al. Periodic alternating gaze. Neurosurgery 20:666-667, 1987. |
| 3. | Senelick RC. "Ping Pong" gaze, Periodic alternating gaze deviation. Neurology 26:532-535, 1976. |
| 4. | Larmande P, Henin D, Jam M, et al. Periodic alternating gaze: Electro-oculographic and anatomical observation of a new case. Neurosurgery 10:263-265, 1972. |
| 5. | Masucci EF, Fabara JA, Saini M, et al. Periodic alternating Ping Pong gaze. Ann Ophthalmol 13:1123-1127, 1981. |
| 6. | Reynard M, Wertenbacker C, Behrens M, et al. "Ping Pong gaze" amplified Neurology 29:757-758, 1979. |
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