Grand Rounds
Eddie Apenbrinck M.D.
University of Louisville School of Medicine
Department of Ophthalmology & Visual Sciences
4/4/2015
Subjective
CC: double vision
HPI: 78 year old white male admitted to the VA
hospital for a fall 2 days prior to admission.
Consulted for new onset horizontal diplopia that
developed after the fall. Patient denied any visual
acuity changes, flashes, floaters, or ocular pain.
POH: Presbyopia
PMHx: hyperlipidemia, hypertension, non-insulin dependent
diabetes
ROS: recent falls, gait instability
Meds: Metformin, Lisinopril 40mg PO BID, Atorvastatin
40mg PO daily, Amlodipine 10mg PO daily
Allergies: NKDA
Social: +smoker (3/4 pack per day); denies alcohol and illicits
Imaging: On admission

MRI/MRA Brain
Generalized parenchymal atrophy and ventricular
dilation
 No acute intracranial abnormalities
 MRA was within normal limits


CT head
Generalized parenchymal atrophy and ventricular
dilation
 No intracranial hemorrhage or mass effect

Exam
OD
VA(cc, near):
OS
20/25
20/25-2
+2.50 readers
Pupils:
4
2
4
2
no RAPD
IOP:
11
12
Exam
Anterior Segment
L/L:
C/S:
Cornea:
AC:
I/L:
Vitreous:
OD
OS
WNL
Ptosis
WNL OU
WNL OU
No cell or flare OU
+NS OU
WNL OU
DFE
Optic Nerve:
Macula, vessels,
periphery:
Pink/Sharp OU
WNL OU; no NPDR OU
Motility
Motility

Video removed 2/2 size
Flair Axial
Pons
Midbrain
T2 Axial
Assessment and Plan

Assessment:


78 year old white male with left internuclear ophthalmoplegia
(INO) caused by a stroke of the left medial longitudinal
fasciculus (MLF) at the junction pons and midbrain
Plan:


Physical therapy for gait training and walker use
Observe with follow up as outpatient in ophthalmology clinic
and neurology clinic
INO

Injury to the MLF, between the abducens nucleus and
the contralateral medial rectus subnucleus of the
oculomotor nerve.



impairs adducting saccades of the ipsilateral eye, which become either
slow or absent
On attempted lateral gaze, away from the side of the lesion, the abducting
eye overshoots the target (dysmetria), giving the appearance of dissociated
(disconjugate) nystagmus.
The 2 most common casues of INO are demyelination
and stroke


Adolescent and young adult= demyelination
Older adults= microvascular diseae
Medial Longitudinal Fasciculus
MLF
Medial Longitudinal Fasciculus
INO

Convergence may be preserved.

A large angle exodeviation may occur in bilateral INO
(“wall-eye” bilateral INO or WEBINO syndrome)

Other clinical features associated with INO include skew
deviation, defective vertical smooth pursuit, impairment
of the vertical VOR, as well as impaired ability to
suppress or cancel the vertical VOR.

INO may occur with a variety of disorders that affect the
brainstem (vascular, demyelinating, and metastatic) and
must be differentiated from the pseudo-INO of
myasthenia or a long-standing exotropia.
One-and-a-half syndrome (Fisher Syndrome)

One-and-a-half syndrome occurs with damage to the
caudal pons that involves the ipsilateral MLF and either
the ipsilateral PPRF or the abducens nucleus.
 results in an ipsilateral gaze palsy with an ipsilateral
INO
 The only intact horizontal movement is abduction of
the contralateral eye.
 The most common causes of the one-and-a-half
syndrome are multiple sclerosis and brainstem stroke,
followed by metastatic and primary brainstem
tumors.
Eight-and-a-half-syndrome

A lesion producing the one-and-a-half syndrome
but also involving the intra-axial portion of the
facial nerve

Stroke is the most common cause
Improvement of Internuclear
Ophthalmoparesis in Multiple Sclerosis with
Dalfampridine

Dalfampridine is a potassium channel blocked used for gait
impairment

3 patient case series, each patient with bilateral INO secondary
to multiple sclerosis

Binocular eye movements were recorded before dalfampridine
10mg (baseline) and 3 hours after dalfampridine 10mg

Each patient showed improvements in horizontal saccadic
conjugacy consistent, possible due to improve neural conduction
along the MLF
References
1.
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BCSC: Neuro-Ophthalmology. Internuclear Ophthalmoplegia. Pgs :209-212
Davis SL, Frohman TC, Crandall CG, et al. Modeling Uthoff’s phenomenon in MS
patients with internuclear ophthalmoparesis. Neurology. 2008;70(13 pt 2):1098-1106.
Epub 2008 Feb 20.
McGettrick P, Eustace P. The W.E.B.I.N.O syndrome. Neuro-ophthalmology.
1985;5;109-115
Mills, DA, Frohman TC, Davis SL, et al. Break in binocular fusion during head
turning in MS patients with INO. Neurology. 2008;71(6)458-460
Epsinosa PS. Teaching NeuroImage: one-and-a-half syndrome. Neurology.
2008;70(5):e20
Frohman TC, Galetta S, Fox R, et al. Pearls & Oy-sters: the medial longitudinal
fasciculus in ocular motor physiology. Neurology. 2008;70(17):e57-e67
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