{"id":3053,"date":"2025-11-18T10:47:47","date_gmt":"2025-11-18T10:47:47","guid":{"rendered":"https:\/\/beyondtheimpact.net\/?p=3053"},"modified":"2025-11-18T10:47:47","modified_gmt":"2025-11-18T10:47:47","slug":"ocular-motor-abnormalities-in-functional-neurological-disorder-fnd-what-new-research-reveals","status":"publish","type":"post","link":"https:\/\/beyondtheimpact.net\/?p=3053","title":{"rendered":"Ocular Motor Abnormalities in Functional Neurological Disorder (FND): What New Research Reveals"},"content":{"rendered":"\n<h1 class=\"wp-block-heading\"><\/h1>\n\n\n\n<p class=\"wp-block-paragraph\">Functional Neurological Disorder (FND) is increasingly recognised as a condition involving disruptions in attention, prediction, and motor control across large-scale brain networks. While the diagnosis is primarily clinical, there is growing interest in <strong>objective markers<\/strong> that support a <em>positive<\/em> diagnostic approach.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A new multicentre study using <strong>video-oculography (VOG)<\/strong>\u2014a precise method of recording eye movements\u2014has provided the largest dataset to date examining <strong>saccades, smooth pursuit, antisaccades, and abnormal eye movement patterns in FND<\/strong>. The findings give us fresh insight into how FND affects cognitive\u2013motor control and may help clinicians differentiate FND from organic neurological diseases in complex presentations.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>1. Why Eye Movements Matter in FND<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Eye movements are tightly linked to networks involved in:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>attention<\/li>\n\n\n\n<li>motor preparation<\/li>\n\n\n\n<li>sensory integration<\/li>\n\n\n\n<li>prediction and inhibition<\/li>\n\n\n\n<li>cognitive control<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Because these systems are directly implicated in FND pathophysiology, ocular motor tasks can reveal subtle abnormalities that may not be detectable in routine clinical examination.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">VOG allows clinicians to objectively measure <strong>latency<\/strong>, <strong>variability<\/strong>, <strong>accuracy (gain)<\/strong> and <strong>error patterns<\/strong>, offering a window into the \u201ceffortful\u201d, inconsistent, and attention-sensitive performance often characteristic of FND.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h1 class=\"wp-block-heading\"><strong>2. Key Findings From the New Study<\/strong><\/h1>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>A. Increased Saccadic Latency<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">One of the most robust findings was <strong>prolonged reaction times (latency)<\/strong> in FND patients across both horizontal and vertical saccades.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>FND patients had significantly longer latencies than healthy controls.<\/li>\n\n\n\n<li>Latencies were similar to, or slightly higher than, patients with multiple sclerosis (MS).<\/li>\n\n\n\n<li>Lateralised symptoms did <em>not<\/em> lead to lateralised saccadic delays.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Clinical meaning:<\/strong><br>Delayed initiation of eye movements reflects the increased cognitive load, heightened self-monitoring, and impaired attentional shifting that characterise FND. This aligns with the broader concept of <em>effortful voluntary control replacing automatic motor processes<\/em>.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>B. Marked Variability \u2013 A Signature of FND<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Perhaps the most important discriminator was <strong>variability<\/strong>.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>FND patients showed <strong>dramatically increased variability<\/strong> in saccade latency compared with both controls and MS patients.<\/li>\n\n\n\n<li>Variability strongly correlated with longer latencies\u2014when patients slowed down, they also became more inconsistent.<\/li>\n\n\n\n<li>Upward vertical saccades were especially variable.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Why this matters:<\/strong><br>Variability is a core positive diagnostic feature in FND\u2014seen across motor, gait, sensory, and speech presentations.<br>Here, VOG quantifies that inconsistency objectively, supporting the clinical picture.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>C. Vertical Saccades: Hypometria and Variability<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Vertical saccades provided another differentiating pattern:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Upward and downward saccades in FND were hypometric<\/strong> (undershooting the target).<\/li>\n\n\n\n<li>Increased <strong>variability<\/strong> of upward saccade gain was characteristic.<\/li>\n\n\n\n<li>MS patients also showed abnormalities, but of different patterns (e.g., more downward variability).<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">This suggests subtle differences in how fronto-parietal and brainstem networks behave in functional vs. structural disorders.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>D. Antisaccade Performance \u2013 Impaired but Non-Specific<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The antisaccade task measures <strong>response inhibition and voluntary control<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Findings:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Both FND and MS groups had <strong>higher error rates<\/strong> than controls.<\/li>\n\n\n\n<li>Latency of corrected responses was also significantly prolonged.<\/li>\n\n\n\n<li>In FND, antisaccade errors increased slightly in patients with psychiatric comorbidities or neurotropic medication use.<\/li>\n\n\n\n<li>When medicated patients were removed, antisaccade errors resembled those of controls.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Interpretation:<\/strong><br>Antisaccade deficits reflect impaired inhibition and increased cognitive load\u2014common in many neuropsychiatric conditions\u2014so this is <strong>not specific to FND<\/strong>.<br>However, in complex cases it contributes to the overall pattern of attentional and executive dysfunction.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>E. Smooth Pursuit \u2013 Often Jerky in FND<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Smooth pursuit abnormalities were notable:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>34% of FND patients<\/strong> showed saccadic (jerky) pursuit<\/li>\n\n\n\n<li>Compared with <strong>18% of controls<\/strong><\/li>\n\n\n\n<li>Less severe than MS (60%), but still a meaningful difference<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Smooth pursuit requires sustained attention and continuous sensorimotor integration\u2014functions often impaired in FND.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>F. Abnormal Eye Movements \u2013 Only in 13% but Highly Characteristic<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Although not frequent, certain <strong>qualitative eye movement disorders<\/strong> were seen in FND:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Convergence spasm<\/strong>: 7%<\/li>\n\n\n\n<li><strong>Pseudo-flutter<\/strong>: 3%<\/li>\n\n\n\n<li><strong>Functional gaze restriction<\/strong>: 5%<\/li>\n\n\n\n<li><strong>Functional ptosis\/blepharospasm<\/strong>: ~3%<\/li>\n\n\n\n<li>Importantly: <strong>no nystagmus<\/strong>, differentiating FND from cerebellar or vestibular pathology.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">These findings mirror previous clinical reports and emphasise that while many FND patients have <em>normal<\/em> baseline eye movements, a minority show distinctive, task-triggered abnormalities.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h1 class=\"wp-block-heading\"><strong>3. How Do Ocular Abnormalities Vary Across FND Subtypes?<\/strong><\/h1>\n\n\n\n<p class=\"wp-block-paragraph\">The study included patients with diverse FND presentations\u2014functional weakness, gait disorders, tremor, dystonia, sensory loss, dissociative seizures, and visual symptoms. Although subgroup analysis was limited, several patterns are noteworthy:<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Functional Motor Symptoms (weakness, gait problems)<\/strong><\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>More likely to show <strong>increased latency<\/strong> and <strong>variability<\/strong>, reflecting global motor planning disruption.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Hyperkinetic FND (tremor, dystonia, jerks)<\/strong><\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Higher likelihood of <strong>smooth pursuit saccadic intrusions<\/strong>, reflecting impaired sensorimotor gating.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Sensory FND \/ Visual Symptoms<\/strong><\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Not clearly associated with distinct VOG findings\u2014eye movement abnormalities were similar across subgroups.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Dissociative Seizures<\/strong><\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Small numbers, but antisaccade performance tended to be worse, consistent with attentional difficulties.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>FND with Psychiatric Comorbidity<\/strong><\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Slight increase in antisaccade errors<\/li>\n\n\n\n<li>No effect on latency or variability<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Overall, <strong>inconsistency and excessive cognitive effort<\/strong> appear common across all phenotypes.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h1 class=\"wp-block-heading\"><strong>4. What This Means for Clinical Practice<\/strong><\/h1>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>A. VOG is not diagnostic\u2014but highly supportive<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The authors emphasise that eye-tracking abnormalities should not be used in isolation. Instead, they:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>strengthen a <em>positive<\/em> FND diagnosis<\/li>\n\n\n\n<li>help differentiate FND from structural disorders in ambiguous cases<\/li>\n\n\n\n<li>prevent misdiagnosis (e.g., suspected cerebellar or brainstem disease)<\/li>\n\n\n\n<li>provide objective data to support discussions with patients<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>B. Variability is the most valuable marker<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">If one feature stands out as \u201ccharacteristic\u201d of FND, it is this:<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\"><strong>Marked variability in saccade latency and gain that exceeds what is seen in both healthy controls and MS.<\/strong><\/p>\n<\/blockquote>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>C. VOG may have therapeutic value<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Objective visualisation of inconsistent or task-dependent abnormalities can help patients understand their condition, enhancing engagement in treatment.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h1 class=\"wp-block-heading\"><strong>5. Final Thoughts<\/strong><\/h1>\n\n\n\n<p class=\"wp-block-paragraph\">This large, rigorous VOG study strengthens the evidence that <strong>FND affects eye movements through disrupted attentional, predictive, and cognitive control mechanisms<\/strong>, not structural pathology.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The most meaningful ocular motor signatures of FND include:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Prolonged saccade latency<\/strong><\/li>\n\n\n\n<li><strong>Marked latency variability<\/strong> (a core positive sign)<\/li>\n\n\n\n<li><strong>Vertical hypometria with variability<\/strong><\/li>\n\n\n\n<li><strong>Jerky smooth pursuit<\/strong><\/li>\n\n\n\n<li><strong>Task-triggered functional eye movement disorders<\/strong> (e.g., convergence spasm)<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">These findings add valuable, objective markers to the clinician\u2019s toolkit\u2014particularly in diagnostically complex cases.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Functional Neurological Disorder (FND) is increasingly recognised as a condition involving disruptions in attention, prediction,&hellip;<\/p>\n","protected":false},"author":5,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"content-type":"","_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[24,153],"tags":[151],"class_list":["post-3053","post","type-post","status-publish","format-standard","hentry","category-biomarkers","category-functional-neurological-disorders","tag-fnd"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.0 - 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