Oculogyric crisis in a patient taking metoclopramide
A 13-year-old female patient presented to the emergency department with double vision and involuntary upward and lateral deviation of the eyes. Three days earlier, she had presented at an outpatient clinic and metoclopramide therapy was started at 0.5 mg/kg three times daily for vomiting of 2 days’ duration. After treatment, the frequency of vomiting was reduced, but her eyes became deviated upward, starting from 30 minutes before presentation (). On initial presentation, she was aware of this situation and was in severe distress. On neurological examination, her consciousness was clear. Sustained conjugate upward and lateral deviation of the eyes (oculogyric crisis), and neck stiffness when only the neck muscles were contracted, were observed. Physical examination did not reveal any other dyskinetic movement. The patient could bring her eyes back to primary position with extreme effort, but she could not sustain the effort, and the eyes resumed their eccentric position within seconds. On ophthalmic examination, she exhibited isocoria, with her pupils giving indirect and direct light reflexes. Ocular motility and visual acuity could not be evaluated due to the presence of oculogyric crisis. Her intraocular pressures and biomicroscopic and fundoscopic findings were unremarkable. Vitals were normal and results of complete blood count, liver and kidney function tests, and electrolytes were within normal values. Based on the history and physical examination findings, a diagnosis of metoclopramide-induced dystonia was made. The drug was discontinued and the patient was treated with intravenous diphenhydramine 1 mg/kg. The symptoms disappeared rapidly, within 30 minutes of commencing treatment, and the patient was discharged after approximately 4 hours of admission with complete recovery. She remained well at follow-up 1 week later.