A patient was diagnosed with schizophrenia and was staed on haloperidol 5mg. On 3rd day he presented with uprolling of eyes. A complete neurological examination revealed no spasticity or any other abnormalities except uprolling of eyeballs. Visual acuity was found to be normal. What is your likely diagnosis?

**Core Concept**
Acute dystonia is a neuropsychiatric side effect of first-generation antipsychotics (typical antipsychotics) like haloperidol, characterized by involuntary, sustained muscle contractions leading to abnormal postures. It commonly affects the neck, face, and eyes, resulting in torticollis or ophthalmoplegia.

**Why the Correct Answer is Right**
Haloperidol blocks dopamine D2 receptors in the nigrostriatal pathway, leading to extrapyramidal side effects. Acute dystonia manifests as sudden, painful muscle spasms. In this case, the patient presents with isolated uprolling of the eyes (ophthalmoplegia), without spasticity or other neurological deficits, which is a classic sign of acute dystonia. This occurs within hours to days of starting or increasing antipsychotic dose, especially in sensitive individuals.

**Why Each Wrong Option is Incorrect**
Option A: Seizure – Seizures involve loss of consciousness, generalized convulsions, or abnormal EEG findings, which are absent here. Eye uprolling alone does not indicate seizure.
Option C: Malingering – Malingering involves intentional faking of symptoms for external gain, but there is no evidence of intent or behavioral manipulation. The presentation is consistent with a drug-induced neurological effect.
Option D: Akathesia – Akathesia presents as restlessness, inner agitation, and an inability to sit still, not with ocular abnormalities. It does not cause eye uprolling.

**Clinical Pearl / High-Yield Fact**
First-generation antipsychotics like haloperidol are associated with acute dystonia, especially in early treatment. Eye uprolling (saccadic dystonia) is a hallmark sign. Prompt recognition and treatment with benzodiazepines or anticholinergics (e.g., benztropine) are essential to prevent complications.

✓ Correct Answer: B. Acute dystonia