The significance of eye opening and closure during paroxysmal events in infants was examined by a retrospective review of video electroencephalograms of 91 seizures recorded in 69 infants at the Epilepsy Center, Children’s Memorial Hospital, Chicago, IL. Infants were awake at the onset of paroxysms in 65 (71.4%) and asleep in 25 (27.5%). Eyes were open sometime during the seizure in 85 (93.4%) cases and closed throughout the event in only 6 (6.6%). Seizures in those with persistent eye closure were unclassified spasms in 3, partial clonic in 2, and generalized myoclonic in 1; these patients had severe neurologic encephalopathy, infections, or West syndrome, consistent with a diagnosis of epilepsy. The majority of infants with seizures have eyes open at some time during the event, and apart from a minority with severe neurologic disorders, infants with persistent eye closure during a sudden paroxysmal event are very unlikely to be diagnosed with epilepsy. 
COMMENT. This report may provide a useful simple aid in the diagnosis of nonepileptic paroxysmal events in infants. The study was triggered by a perceptive resident’s observation that an infant’s eyes were closed throughout a paroxysmal event in a case presented on pediatric intake rounds, a finding considered unusual for an epileptic seizure.
In response to my question regarding the mechanism of eye opening during seizures and whether it could be related to frontal lobe or brain stem excitation, Dr Nordli answered as follows: “I am not sure, but the eye opening is probably not a direct ictal feature, but rather in keeping with a more diffuse alerting response to seizures.”
The differential diagnosis of nonepileptic paroxysmal events in infants and young children includes breath-holding spells, gastroesophageal reflux, hypocalcemic tetany, shuddering attacks (Ped Neur Briefs Feb 1992) , hyperekplexia (Ped Neur Briefs May 1991) , and syncope. Paroxysmal symptoms involving the eyes, sometimes misdiagnosed as seizures, include tonic upgaze of infancy (Ped Neur Briefs April 2005;19:32) , paroxysmal ocular downard deviation (Ped Neur Briefs Feb 1992) , spasmus nutans, and opsoclonus-myoclonus syndrome. (For further case reports of epileptic and nonepileptic paroxysmal events in infants, see Progress in Pediatric Neurology I-III, PNB Publishers, 1991, 94, & 97).