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Pitch plane signs include vertical nystagmus (upbeat or downbeat), forward or backward tilts and falls, and superior or inferior deviation of the perceived straight-ahead position, while roll plane signs consist of torsional nystagmus, vertical or oblique misalignment of the eyes, tilts of the head and body.
Other associated findings are abnormalities in vertical smooth pursuit, optokinetic nystagmus; gaze evoked vertical nystagmus on upward gaze more frequent than downgaze if the lesion is bilateral and skew deviation.
Fast-phase vertical nystagmus is directed down, and torsional nystagmus of the superior pole of the eye is directed toward the affected ear.
The neurologist noted vertical nystagmus, slight impairment of lateral gaze, and upon walking the patient, pronounced midline ataxia.