Bilateral internuclear ophthalmoplegia—an unusual initial presenting sign of giant cell arteritis

Abstract

A 63-year-old man presented six days after the sudden onset of horizontal double vision. His left eye became divergent two days later. On initial examination he had bilateral internuclear ophthalmoplegia with weakness of adduction and abducting nystagmus. Convergence was weak but there were no other neuro-ophthalmic signs. Constitutional signs included confusion and unsteadiness on his feet. A provisional diagnosis of arteritis was made. His ESR was 92 mmlh and a superficial temporal artery biopsy confirmed the diagnosis of giant cell arteritis. After two weeks or oral prednisolone his eye movements returned to normal. There have been no further relapses.This would appear to be a unique presentation of giant cell arteritis. The causes of internuclear ophthalmoplegia are discussed along with a review of the ocular and neuro-ophthalmic signs of giant cell arteritis.

Diagnosis and management of giant cell arteritis: Major review

“…It can present with third (usually pupil sparing and rarely pupil involving), fourth and sixth cranial nerve palsies 65,66 . Bilateral internuclear ophthalmoplegia and postural change induced one and a half syndrome have also been reported 48,67 …”

“…65,66 Bilateral internuclear ophthalmoplegia and postural change induced one and a half syndrome have also been reported. 48,67…”

Clinical Reasoning: Woman With Acute Bilateral Ophthalmoplegia

“…5 One case presented with bilateral oculomotor nerve plegia 4 and the other cases all involved bilateral internuclear opthalmoplegia. [6][7][8] The mechanism of ophthalmoplegia in GCA is from ophthalmic artery and vasa nervorum ischemia, which supply the extraocular muscles and the oculomotor nerves respectively. 3 This case represents an atypical presentation of GCA.…”

“…3 Since then, there have been a handful of other case reports of bilateral ophthalmoplegia related to GCA. 4-8 Only 1 of the 5 cases involved bilateral cranial nerves III and VI. 5 One case presented with bilateral oculomotor nerve plegia, 4 and all other cases involved bilateral internuclear ophthalmoplegia.…”

Bilateral Internuclear Ophthalmoplegia: An Initial Presenting Sign of Giant Cell Arteritis

“…Brainstem infarction has been reported in association with giant cell arteritis. There have been a few reports of biopsy‐proven internuclear ophthalmoplegia caused by giant cell arteritis 13–15 and some presumed cases as well 16 . We present a case of bilateral internuclear ophthalmoplegia associated with biopsy‐proven giant cell arteritis.…”