Pontine infarction responsible for wall-eyed bilateral internuclear ophthalmoplegia syndrome

A 68-year-old man with hypertension, cardiac arrhythmia, and a mechanical heart valve replacement treated with vitamin K antagonists was admitted for the acute onset of diplopia. Neuro-ophthalmologic examination showed a bilateral exotropia in primary gaze position (wall-eyed) with bilateral adduction deficit that did not improve by convergence (figure, video at Neurology.org/cp). In lateral gaze, a horizontal nystagmus of the abducting eyes appeared. Vertical saccades were normal (video). Pupils were symmetric and reactive to light. Brain MRI with diffusion-weighted images showed an acute pontine ischemic lesion (figure). Echocardiography revealed a thrombus in left auricle and anticoagulants were optimized. Neuro-ophthalmologic symptoms progressively improved over 3 months (video).

Source: Nature Clinical Practice - December 8, 2014 Category: Neurology Authors: Mathis, T., Ducray, F., Tilikete, C., Vighetto, A., Biotti, D. Tags: Clinical neurology examination, All Neuro-ophthalmology, Ocular motility, Diplopia (double vision), All Cerebrovascular disease/Stroke Cases Source Type: research