Floccular inhibition of the vestibulo-ocular reflex in man

The vestibulo-ocular reflex (VOR) plays a major role in ocular motility. Stimulation of each semicircular canal produces excitation of a specific extraocular muscle and inhibition of its antagonist in each eye. Floccular inhibition of the VOR has been extensively studied in the rabbit. Inhibitory projections from floccular Purkinje cells reach the ipsilateral vestibular nucleus via the restiform body and selectively control certain VORs. We examined the ocular functions in a patient with a lateral lower pontine infarct that included the restiform body. The patient exhibited unilateral, selective disinhibition of the VOR manifested by disconjugate upward rotatory drift of the eyes at the end of lateral eye movement towards the side of the lesion. He had marked directional preponderance on caloric testing. The same underlying mechanism which produced the biased VOR also appeared to affect target position determination in fast eye movements, resulting in lateropulsion of saccades and asymmetric OKNs. This is the first clinical case supporting the theory of selective cerebellar inhibition of the VOR.