Presented by Geo Paul A J June 19, 2012

Internuclear ophthalmoplegia
Brief review of innervations and tracts
Lesion Signs and symptoms Physical exam findings Associated syndromes Etiology/Differential diagnosis Confirmation of diagnosis Prognosis and treatment

RIGHT

TO LOOK TO LEFT SIDE

LEFT

RE (R) FRONTAL EYE FIELD

LE

Fronto Pontine pthway Occulomotor Nucleus

(L) PPRF MLF

Abducens nuclear complex

Site Of Lesion
MLF : A pair of white matter tract that lie near the

midline just under the 4th venticle and cerebral aqueduct Extentsion: Abducens nucleus to opposite side 3rd nerve nucleus Lesion of MLF occurs either in dorsomedial pons or tegmentum of midbrain Side of lesion: side of adduction defect or side of MLF lesion, i.e in Rt INO Rt side MLF affected

RIGHT

WHILE LOOKING TO LEFT SIDE in Rt INO

LEFT

RE FRONTAL EYE FIELD

LE

Occulomotor Nucleus

Fronto Pontine pathway

PPRF MLF

Abducens nuclear complex

Signs and symptoms

Reading fatigue
Horizontal diplopia Oscillopsia Loss of stereopsis (depth perception) Vertigo

Physical examination
Unable to adduct or impaired adduction on

lateral gaze
Nystagmus in contralateral abducting eye
Convergence preserved Abduction slowing in affeted eye

Why is there nystagmus of the contralateral eye?

2 theories:
Herings law of equal innervation: Adaptive

response to overcome the weakness of the cotralateral MR

Lesion also affects vestibular nuclei => should

be nystagmus in both eyes => cant elicit in affected eye due to adductor weakness

Associated syndromes
One and half syndrome
WEBINO: Wall eyed bilateral INO

One and a half syndrome

Lesion involving PPRF

and MLF
Internuclear

ophthalmoplegia
Conjugate horizontal

gaze palsy in one direction

Wall eyed bilateral INO

Involve bilateral MLF pathways Demyelinating syndrome -Multiple

Sclerosis

Aetiology
Multiple Sclerosis
33% of cases Age <45 yrs Usually bilateral

CVA
Ischemic infraction Lacunar infraction of

penetrating arteries originating from basilar artery Older persons: 62-66 yrs
HTN, DM, Smoking 90% unilateral

Priventricular location

 Other vascular causes Haemorrgic Vascular malformation Vertebral artery dissection Vasulitis

Infection Trauma Mets

Differential Diagnosis
Partial 3rd Nerve palsy
No nystagmus in

Progressive supranuclear palsy

Parkinsonism features will be

contralateral eye Difficulty looking up Ptosis Pupil dilation

present

Pseudo INO
GBS- Miller fischer variant
Areflexia Ataxia Limb weakness

Myasthenia Gravis
Ptosis Lid lag

Diagnosis
MRI- Diiffuson weighted MRI: Acute infarction
Proton Density imaging : MS Oculographic recording and opticokinetic tape: to

detect velocity and acceleration of abduction and adduction

Treatment
Treat underlying cause/risk factors
Time may take months to improve Patch eye as a temporizing measure for diplopia