Since the second meeting of the nystagmus subcommittee I have been considering how best to reconcile the need for a ‘fixation’ protocol which stands alone from nystagmus while at the same time providing clear guidance for assessing nystagmus.

On the one hand, a ‘fixation’ protocol needs to be agnostic to the clinical condition (so that it can be used in contexts beyond nystagmus). On the other hand, if we only produce a basic fixation protocol with no guidance on how to apply it in nystagmus, then we aren’t really any closer to clinical standardisation (the point of ISCET guidelines is to ensure patients receive a similar standard of care across clinics).

I would therefore like to propose a ‘layered’ approach, with the nystagmus subcommittee producing two distinct outputs:

1. A ‘core’ fixation protocol, which does not mention nystagmus, and is generally applicable across a range of clinical contexts. This core protocol could then be reused in other conditions, as necessary.
2. Nystagmus-specific guidance, which specifies the particular viewing conditions / gaze angles etc over which to apply the fixation protocol. If the group deem it necessary, then other ‘core’ protocols (e.g. OKN/saccades etc) could also be referenced in this layer.

With this approach we would end up with a set of ‘core’ protocols for each eye movement system (fixation, OKN, saccades, etc), and then a ‘higher level’ set of disease-specific protocols (nystagmus, Huntington’s disease, PSP, etc) which refer to the core protocols.

Would be interested to hear others thoughts on this approach, and I would love to hear suggestions for alternatives or refinements to this. And, so far as is appropriate, we should probably try to replicate the structure of ISCEV protocols, so their guidance will be especially helpful.