“EYES ON CEILING SIGN”: a new ocular sign in progressive supranuclear palsy

There are many clinical ocular signs such the "round the house" sign,[1] wall-eyed bilateral internuclear ophthalmoplegia,[2] apraxia of the eyelid opening,[3] and eyelid closure[4] in progressive supranuclear palsy (PSP). In this communication, I describe a new clinical sign observed in early PSP, which I have named "eyes on ceiling" sign. When one gets up from the lying position, the eyes usually go down and the neck flexes before attempting to sit up from the supine position. However, in PSP, it was observed that when a patient gets up from the supine position, the eyes remain glued to the ceiling even after the act of sitting up has been completed. This can be observed even before the patient develops complete downward gaze palsy. A 60-year-old man presented with a history of slurring of speech and two episodes fall backwards for the last 3 months. On examination, he had mild slowness of both the vertical and horizontal saccades with full range of eye movements. The patient had no rigidity, akinesia, or tremor. The "applause sign" was negative. The pull test was positive [Video 1]. On asking the patient to get up from the lying position, his eyes remained glued to the ceiling for some time even after sitting up [Video 2]. On lying back on the cot, there was no change in the position of his eyes. This sign suggested the diagnosis of PSP, in addition to dysarthria and postural imbalance evinced by the positive "pull test." Brain magnetic resonance imaging showed the "morning glory sign" [Figure 1]. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_7p5fvjna"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_kltaz2bp"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Figure 1:: Brain magnetic imaging showing the "morning glory sign"Video 3 shows the same phenomenon in a 64-year-old patient with PSP. This patient had a positive pull test, in addition to mild generalized akinesia. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_2cq9ywpi"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The sign is similar to the applause sign, which is not specific to PSP. This new sign only indicates supranuclear ophthalmoparesis with intact vestibulo-ocular reflex and may be observed in early PSP-Richardson-steele syndrome only. The possible explanation for this phenomenon may be a combination of several factors such as defective downward saccade, nuchal dystonia in the wake of intact oculocephalic reflex. The intact oculocephalic reflex in the presence of defective downward saccade may have been responsible for the inability of these patients to shift their gaze from the ceiling. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Acknowledgement I hereby certify that the work shown here is genuine, original and not submitted anywhere, either in part or full. They transfer the full rights of the video to Neurology India. All the necessary permissions from the patient, hospital and institution has been taken for submitting this video to Neurology India Author contribution I am solely involved in the conception and design or acquisition of data or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published Ethical compliance statement Informed consent is obtained from the patients. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.