This is an old revision of the document!
Signs and Symptoms of Seizures detectable Pediatric Eye Exam
Distinguishing Benign Non-Epileptic Ocular Paroxysmal Events from Seizures in Infants
Preserved consciousness, normal horizontal eye movements, absence of postictal features, and a normal ictal EEG are the key clinical discriminators that separate benign non-epileptic ocular paroxysmal events from seizures — but because clinical features overlap substantially in infants, polygraphic video-EEG remains the criterion standard when doubt persists (Falsaperla et al., Pediatr Neurol 2021; Lőrincz-Molnár et al., Dev Med Child Neurol 2026; Kartal, Pediatr Emerg Care 2019). The single most reliable clinical maneuver is capturing the event (ideally on parental video) and assessing responsiveness, the character of the eye movements, triggers, and the state (sleep vs. wake) during the episode (Falsaperla et al., Pediatr Neurol 2021; Lagorio et al., Neurol Clin Pract 2022).
General Features Favoring a Benign Non-Epileptic Event
- Retained consciousness/responsiveness during the episode, with the child able to interact, is characteristic of benign ocular events and argues against most seizure types (Kartal, Pediatr Emerg Care 2019; Bonnet et al., Mov Disord 2010).
- Specific triggers and relief by sleep — exacerbation by febrile/intercurrent illness or fatigue, diurnal fluctuation, and cessation during sleep are typical of benign events; epileptic events are generally not abolished by sleep (Bonnet et al., Mov Disord 2010; Lazar & Abid, Neurology 2024).
- Absence of a postictal state (no lethargy, confusion, or Todd paresis) and no accompanying autonomic changes (apnea, marked hypertension, cyanosis) point away from seizure (Beinvogl et al., Pediatrics 2016; Lagorio et al., Neurol Clin Pract 2022).
- Semiology on video-EEG series — tremor, stereotyped semiology, akinetic and asynchronous movements, and agonist-antagonist alternating movements were almost exclusively non-epileptic, whereas arrest (in infants <3 y), tonic semiology, spasms, and hypermotor activity favored epilepsy (Lőrincz-Molnár et al., Dev Med Child Neurol 2026).
- Normal interictal and ictal EEG with a normal neurodevelopmental trajectory ultimately confirms the benign nature — often a retrospective diagnosis (Paolicchi, Epilepsia 2002; Karpuzcu et al., Seizure 2026).
Benign Paroxysmal Tonic Upgaze (PTU)
Distinguishing features that separate PTU from seizures (e.g., partial seizures or atypical absences, for which these children are frequently referred) (Bonnet et al., Mov Disord 2010):
- Sustained or intermittent conjugate upward eye deviation (seconds to hours, occasionally days) with compensatory neck flexion (chin-down) and down-beating saccades on attempted downgaze (Bonnet et al., Mov Disord 2010; Lazar & Abid, Neurology 2024).
- Normal horizontal eye movements and no clouding of consciousness (Bonnet et al., Mov Disord 2010).
- Onset usually <1 year, diurnal fluctuation, exacerbation with fever/fatigue, relief by sleep, and frequently associated ataxia/clumsiness (Bonnet et al., Mov Disord 2010; Lazar & Abid, Neurology 2024).
- Generally normal investigations (EEG, MRI, CSF neurotransmitters), though PTU can rarely coexist with occipital EEG discharges and be misdiagnosed as epilepsy — video-EEG with the attack captured resolves this. Some cases have a genetic basis (e.g., CACNA1A) or structural associations, so persistent/atypical cases warrant workup (Lazar & Abid, Neurology 2024; Zhang et al., J Int Med Res 2021).
Spasmus Nutans
- Classic triad — asymmetric or monocular, high-frequency, small-amplitude pendular nystagmus; head nodding; and torticollis/anomalous head position. The nystagmus (rather than a stare or eye deviation) and its intermittent, fine, shimmering quality are the discriminators from an ictal event (Lagorio et al., Neurol Clin Pract 2022; Bellini et al., Neurology 2022; Gottlob et al., Ophthalmology 1990).
- Onset in infancy with self-limited course, usually resolving within ~2 years (Lagorio et al., Neurol Clin Pract 2022; Bellini et al., Neurology 2022).
- Critical caveat — benign spasmus nutans cannot be reliably distinguished from spasmus nutans-like disease (chiasmatic/diencephalic gliomas, retinal dystrophies, visual pathway lesions) on eye/head movement recordings alone; neuroimaging (MRI) and full ophthalmologic/fundoscopic and often electroretinographic evaluation are mandatory to exclude a structural or retinal cause (Bellini et al., Neurology 2022; Gottlob et al., Ophthalmology 1990).
Other Benign Infantile Mimics
Each has preserved consciousness and a normal EEG: shuddering attacks/benign myoclonus of early infancy, benign paroxysmal torticollis, Sandifer syndrome (dystonic posturing during/after feeding with GERD), non-epileptic head drops, and opsoclonus (which must prompt evaluation for neuroblastoma) (Beinvogl et al., Pediatrics 2016; Lagorio et al., Neurol Clin Pract 2022; Paolicchi, Epilepsia 2002).
One important non-benign mimic is Glut1 deficiency syndrome, in which paroxysmal eye-head movements often begin before 6 months and precede seizures; these gaze-saccade movements are distinguished from opsoclonus by a clear intermovement fixation interval and a same-direction head movement, and recognition matters because the condition is treatable (Pearson et al., Neurology 2017).
Key Principle
Polygraphic video-EEG/EMG demonstrating paroxysmal motor activity (e.g., shuddering) with a completely normal concurrent EEG confirms a non-epileptic event (Caraballo et al., Epilepsia 2009).