Internuclear ophthalmoplegia and contralateral exotropia Nonparalytic pontine exotropia and WEBINO syndrome

Komiyama, Atsushi; Takamatsu, Kazuhiro; Johkura, Ken; Hasegawa, Osamu; Fukutake, Toshio; Hirayama, Keizo

doi:10.1076/noph.19.1.33.3691

Cited by 20 publications

(13 citation statements)

References 3 publications

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“…As the lesions of PSP characteristically involve the pontine and midbrain tegmentum and those of WEBINO involve the same regions (1,10), the appearance of WEBINO in PSP is not surprising. Brain MRI for this patient did reveal atrophic changes in the midbrain tegmentum, a finding previously described in WEBINO (11).…”

Section: Discussionmentioning

confidence: 99%

Wall-Eyed Bilateral Internuclear Ophthalmoplegia in a Patient with Progressive Supranuclear Palsy

Ushio

Iwasaki

Chihara

et al. 2008

Journal of Neuro-Ophthalmology

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Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is a rare disorder consisting of a bilateral adduction deficit and primary gaze position exotropia. Associated with bilateral medial longitudinal fasciculus lesions, it has been mostly reported in patients with multiple sclerosis and brainstem stroke. A 72-year-old man with characteristic clinical features of progressive supranuclear palsy (PSP) later developed WEBINO. Brain MRI revealed atrophy of the midbrain tegmentum. Caloric irrigation revealed intact horizontal eye movements in both eyes. We believe this to be the first report of WEBINO in PSP. The preservation of vestibulo-ocular horizontal eye movements supports the notion that the WEBINO in this condition was caused by a supranuclear rather than a nuclear lesion and suggests the possibility that even in other causes of WEBINO, the lesion is supranuclear and not in the medial rectus subnucleus as is often suggested.

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Section: Discussionmentioning

confidence: 99%

Wall-Eyed Bilateral Internuclear Ophthalmoplegia in a Patient with Progressive Supranuclear Palsy

Ushio

Iwasaki

Chihara

et al. 2008

Journal of Neuro-Ophthalmology

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“…In previously reported patients, contralateral outward eye deviations have been commoner in those with both MLF and PPRF lesions (paralytic and nonparalytic pontine exotropia) than have ipsilateral outward eye deviations, even when the MLF lesion has been dominant [6, 8]. In addition to conjugate deviation, we have reported that secondary deviation induced by overexcitation of the contralateral PPRF under fixation with the ipsilateral eye is also involved in the development or aggravation of contralateral exotropia [8]. However, the reason for preferential fixation with the ipsilateral eye remains undetermined [7, 8].…”

Section: Discussionmentioning

confidence: 99%

“…In addition to conjugate deviation, we have reported that secondary deviation induced by overexcitation of the contralateral PPRF under fixation with the ipsilateral eye is also involved in the development or aggravation of contralateral exotropia [8]. However, the reason for preferential fixation with the ipsilateral eye remains undetermined [7, 8]. According to the present hypothesis, when eye fixation is eliminated, the ipsilateral eye deviates outwardly due to an imbalance of vestibular signals in the MLF, and the contralateral eye deviates outwardly due to an imbalance of PPRF signals (fig.…”

Section: Discussionmentioning

confidence: 99%

“…However, such exotropia is usually described during attempts at forward gaze with the ipsilateral eye fixing [3]. Under this condition, forward gaze may lead to a secondary deviation of the contralateral eye through overexcitation of the contralateral PPRF [7, 8]. Moreover, eyes aligned in the primary position when attempting forward gaze in one-and-a-half syndrome may possibly result from adaptation of the exotropic eye for biocular fixation.…”

Section: Introductionmentioning

confidence: 99%

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Eye Deviation in Patients with One-and-a-Half Syndrome

Johkura

Komiyama²,

Kuroiwa³

2000

Eur Neurol

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To understand malalignments of the visual axes in one-and-a-half syndrome, we measured eye positions in 4 patients with this syndrome under two conditions: with Frenzel goggles to prevent eye fixation and without Frenzel goggles. When fixation was prevented with the Frenzel goggles, all patients showed mild outward deviation in both eyes. Removal of the Frenzel goggles elicited adduction of the eye ipsilateral to the side of the lesion for fixation, with greater outward deviation of the contralateral eye (acute stage), or adduction of both eyes to midposition for biocular fixation (convalescent stage). In 3 patients whose outward eye deviation with Frenzel goggles was greater on the ipsilateral side, a transition from one-and-a-half syndrome to ipsilateral internuclear ophthalmoplegia was noted, whereas a transition to ipsilateral gaze palsy was seen in the one patient whose deviation was greater on the contralateral side. These findings suggest that in one-and-a-half syndrome patients, the eyes tend to be in divergent positions when fixation is prevented; ipsilateral eye deviation may result from medial longitudinal fasciculus involvement, and contralateral eye deviation may result from paramedian pontine reticular formation involvement. Viewing a target may lead to a secondary deviation or adaptation of eye positions for fixation.

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“…Possibly because the signs tend to be short-lived, it has rarely been reported since then, mainly in the French and Japanese literature 10. Previous authors have postulated a secondary deviation of the contralateral eye through overexcitation of the contralateral paramedian pontine reticular formation (PPRF) on attempts to fixate with the ipsilateral paretic eye 10 12…”

Section: Discussionmentioning

confidence: 99%

Unilateral internuclear ophthalmoplegia, strabismus and transient torsional nystagmus in focal pontine infarction

Haider¹

2016

BMJ Case Reports

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Vertebrobasilar stroke carries a high mortality rate and can have symptom patterns that are complex and difficult to diagnose. Isolated infarcts of the pons are uncommon and the neuro-ophthalmic presentation of pontine stroke can be quite variable. There is a paucity of cases in the literature documenting neuro-ophthalmic pathology as the sole or primary manifestation of pontine stroke. Here is presented the case of a unilateral internuclear ophthalmoplegia (INO) with concomitant skew deviation, contralesional exotropia and ipsiversive torsional nystagmus as the initial and only presenting feature of an isolated pontine stroke. This case illustrates the need to consider a cerebrovascular event early in the differential of a complex ocular motility disturbance not in keeping with specific cranial nerve palsy. It similarly highlights non-paralytic pontine exotropia and skew deviation as important causes of acute onset acquired strabismus, and transient torsional nystagmus as a rare but relevant localising feature in pontine strokes causing INO. Acute onset of this constellation of signs is highly suggestive of pontine infarction.

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Internuclear ophthalmoplegia and contralateral exotropia Nonparalytic pontine exotropia and WEBINO syndrome

Cited by 20 publications

References 3 publications

Wall-Eyed Bilateral Internuclear Ophthalmoplegia in a Patient with Progressive Supranuclear Palsy

Wall-Eyed Bilateral Internuclear Ophthalmoplegia in a Patient with Progressive Supranuclear Palsy

Eye Deviation in Patients with One-and-a-Half Syndrome

Unilateral internuclear ophthalmoplegia, strabismus and transient torsional nystagmus in focal pontine infarction

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