Signs and Symptoms of Seizures detectable during the Pediatric Eye Exam

• Behavioral arrest with a fixed stare (pause/stare) and eye involvement
  • Among the most frequent semiologic features of childhood absence epilepsy—eye involvement occurred in a substantial proportion of seizures, and staring was nearly universal.
  • A child who abruptly stops, stares, and has subtle eye movements or automatisms during an exam may be having an absence seizure
• Tonic eye/gaze deviation and head version
  • Conjugate deviation of the eyes (often with head turning) is a classic ictal sign;
  • Frontal-eye-field focus typically drives contralateral eye deviation
  • Posterior-cortex seizures, eye deviation was seen in about one third of young children
• Ictal nystagmus
  • Isolated presentation of focal seizures localizing to the posterior quadrant (occipital, parietal, posterior temporal), with the fast phase directed away from the seizure focus
  • Nystagmus was the most common oculomotor feature (≈39%) in symptomatic posterior-cortex seizures in young children.
• Lid myoclonia
  • Rapid repetitive blinking, eyelid fluttering, and repeated eye closure
  • eyelid myoclonia (~28%) and rapid blinking (~17%) are recognized ictal features, and eyelid fluttering/repeated eye closure are described in childhood occipital visual epilepsy
• Head nodding and opsoclonic movements
  • In very young children, myoclonic head nodding is common, and opsoclonus-like movements can occur

• Elementary visual phenomena
  • Small multicolored circles/spots seen in peripheral vision, moving horizontally across the field, occur in childhood occipital visual epilepsy
  • Younger children may be unable to describe these but can draw them
  • Providing coloring pencils is a practical bedside technique
• Complex visual hallucinations or illusions
  • palinopsia, micropsia, metamorphopsia, and formed hallucinations point to occipital/temporal onset
• Ictal blindness (amaurosis), scotomas, or hemifield/quadrant visual loss
  • “Negative” visual symptoms contralateral to an occipital focus
  • Transient visual loss can occur preictally, ictally, or postictally
• Photic-induced visual seizures
  • lights, colored spots, or visual blurring triggered by flickering light/video games, often with the sensation of following the visual phenomenon (head/eye version), in photosensitive occipital lobe epilepsy
• Associated features
  • Orbital pain
  • Postictal migraine-like headache with nausea/vomiting are common accompaniments of occipital seizures

Routine complete ophthalmologic examination after a first seizure has low yield and generally does not alter acute management in a neurologically normal child.

• Papilledema
  • Consider neuroimaging, seizure can rarely be the first symptom of a brain tumor.
• Visual field deficits(e.g., homonymous quadrantanopia) may reveal a structural occipital lesion causing seizure
• Characteristic fundus abnormalities
  • Chorioretinal lacunae in [Aicardi syndrome] presenting with epileptic spasms and hypsarrhythmia.[10]

• Many paroxysmal ocular events in infants are non-epileptic (e.g., spasmus nutans, benign paroxysmal tonic upgaze, opsoclonus, tonic downgaze)
• Often requires polygraphic video-EEG rather than clinical observation alone.
• A history of unprovoked, short-lasting, stereotyped events—supports an epileptic origin
• Visual symptoms alone should not be used to definitively diagnose seizure type, as this can lead to mistreatment

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).

• 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).

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).

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).

Spasmus Nutans Benign Tonic Gaze (upgaze or downgaze)

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).

1. Beinvogl BC, et al. A 10-Month-Old With Intermittent Hypotonia and Paralysis. Pediatrics. 2016
2. Falsaperla R, et al. Ocular Motor Paroxysmal Events in Neonates and Infants: A Review of the Literature. Pediatr Neurol. 2021
3. Kartal A. Paroxysmal Tonic Upgaze in Children: Three Case Reports and a Review of the Literature. Pediatr Emerg Care. 2019
4. Lőrincz-Molnár T, et al. Semiological Features of Epilepsy Seizures and Paroxysmal Non-Epileptic Events in Children: A Systematic Review and Meta-Analysis. Dev Med Child Neurol. 2026
5. Lagorio I, et al. Paroxysmal Nonepileptic Events in Children: A Video Gallery and a Guide for Differential Diagnosis. Neurol Clin Pract. 2022
6. Bonnet C, et al. Developmental and Benign Movement Disorders in Childhood. Mov Disord. 2010
7. Lazar SM, Abid F. Pearls & Oy-Sters: CACNA1A-Related Paroxysmal Tonic Upgaze With Ataxia Responsive to Acetazolamide. Neurology. 2024
8. Paolicchi JM. The Spectrum of Nonepileptic Events in Children. Epilepsia. 2002
9. Karpuzcu H, et al. Electroencephalography in the Differential Diagnosis of Non-Epileptic Paroxysmal Events in Infants. Seizure. 2026
10. Zhang YF, et al. Paroxysmal Tonic Upgaze Accompanied by Occipital Discharge on Electroencephalography. J Int Med Res. 2021
11. Bellini T, et al. Teaching Video NeuroImage: Spasmus Nutans, an Infantile Nystagmus. Neurology. 2022
12. Gottlob I, et al. Signs Distinguishing Spasmus Nutans (With and Without CNS Lesions) From Infantile Nystagmus. Ophthalmology. 1990
13. Pearson TS, et al. Paroxysmal Eye-Head Movements in Glut1 Deficiency Syndrome. Neurology. 2017
14. Caraballo RH, et al. The Spectrum of Benign Myoclonus of Early Infancy. Epilepsia. 2009
15. * Elucidating the Visual Phenomena in Epilepsy: A Mini Review. Akyuz E, Arulsamy A, Hasanli S, Yilmaz EB, Shaikh MF. Epilepsy Research. 2023;190:107093. doi:10.1016/j.eplepsyres.2023.107093.

• The role of fundoscopy in pediatric seizures. Kassem L, Segal I, Chayen G, Jacob R. European Journal of Pediatrics. 2022;181(1):399-402. doi:10.1007/s00431-021-04167-z.
• Is There a Need for Ophthalmological Examinations After a First Seizure in Paediatric Patients?. Bernhard MK, Gläser A, Ulrich K, Merkenschlager A. European Journal of Pediatrics. 2010;169(1):31-3. doi:10.1007/s00431-009-0966-4.

10. Teaching Video NeuroImages: Epileptic Spasms and Characteristic Ophthalmologic Findings: A Diagnostic Conundrum. Reddy C, Basil M, Madaan P, et al. Neurology. 2020;95(18):e2602-e2604. doi:10.1212/WNL.0000000000010424. Ocular Motor Paroxysmal Events in Neonates and Infants: A Review of the Literature. Falsaperla R, Saporito MAN, Pisani F, et al. Pediatric Neurology. 2021;117:4-9. doi:10.1016/j.pediatrneurol.2020.06.001.