Common causes are multiple sclerosis in young people often bilateral and stroke in the elderly typically unilateral. Transposition surgery for internuclear ophthalmoplegia. Internuclear ophthalmoplegia an overview sciencedirect. Left shows the diffusionweighted image, showing an acute stroke of the dorsal tegmental pons, also evident on the flair sequence on the right. Walleyed bilateral internuclear ophthalmoplegia webino syndrome has previously been reported in only 2 patients with. Internuclear ophthalmoplegia brain, spinal cord, and. Horizontal saccades are initiated by the frontal eye field area of the contralateral frontal lobe ie, the right frontal eye field initiates leftward saccades. Antiacetylcholine receptor antibodies were present in the. Internuclear ophthalmoplegia named for the adducting eye and ipsilateral to the affected mlf horizontal nystagmus in the abducting eye frequently associated with upbeating. Thirty patients presenting with ino without n 12 or with n 18 minimal other neurologic signs were studied.
An unusual aetiology for internuclear ophthalmoplegia. First, we will briefly explain how normal horizontal gaze is mediated figure 2. Jun 12, 20 internuclear, ophthalmoplegia, mlf, syndrome, medial longitudinal fasciculus, lesions of mlf, ino, neurology, anatomy, phys. This man developed a sudden onset right internuclear ophthalmoplegia. The sixth nerve nucleus contains motor neurons that innervate the ipsilateral lateral rectus and interneurons that cross the midline and form the. Marcus toral ba, jaclyn haugsdal, md, michael wall, md. Brainstem syndromes, internuclear ophthalmoplegia, nine syndrome, pontine vascular syndromes. Pseudointernuclear ophthalmoplegia as a presenting feature. It is a common finding in multiple sclerosis, but has a number of other etiologies. Axial t1weighted b and t2weighted c images showed an enhancing lesion in the medial longitudinal fasciculus. Jun, 2014 a 16yearold girl presented with fluctuating diplopia, ptosis of the left eye and an internuclear ophthalmoplegia ino. We describe 3 patients who had complete ophthalmoplegia as a manifestation of bilateral paramedian midbrainthalamic infarction, and we discuss possible pathophysiologic mechanisms. Supranuclear ophthalmoplegia medigoo health medical tests. Internuclear ophthalmoplegia results from a lesion in the medial longitudinal fasciculus, which coordinates abduction of one eye with adduction of the other.
Bilateral internuclear ophthalmoplegia in multiple. Antiacetylcholine receptor antibodies were present in the serum. We present a case of a gentleman with atypical headache symptoms clinically diagnosed as giant cell arteritis gca and initiated on high dose oral steroids. This is usually associated with multiple sclerosis however any pathology of this anatomical region can result in this clinical picture. Internuclear ophthalmoplegia neurologic disorders merck. Prognosis of ischemic internuclear ophthalmoplegia. Internuclear ophthalmoplegia ino describes a clinical syndrome of impaired adduction in one eye with dissociated horizontal nystagmus of the other abducting eye, due to a lesion in the medial longitudinal fasciculus mlf ipsilateral to the eye. A ct scan of the brain revealed 3 to 4 cm of vasogenic edema in the right posteroinferior parietaloccipital area. A brainstem lesion of any type that involves the medial longitudinal fasciculus mlf can cause internuclear ophthalmoplegia ino. Internuclear ophthalmoplegia is a condition which affects nerves and limits eye movement.
Internuclear ophthalmoplegia is related to dysfunction of the medial longitudinal. The condition can be caused by any of several neurologic disorders. The complete ophthalmoplegia can be partly accounted for by bilateral third nerve palsies attributable to involvement of the oculomotor nucleifascicles with a supranuclear vertical gaze palsy attributable to involvement of the rostral interstitial nucleus of the medial longitudinal fasciculus rimlf. We describe 3 patients who had complete ophthalmoplegia as a manifestation of bilateral paramedian midbrainthalamic infarction, and we discuss possible pathophysiologic. These fibers connect collections of nerve cells centers or nuclei that originate from the 3rd cranial nerve oculomotor nerve, the 4th cranial nerve trochlear nerve, and the 6th cranial nerve. Progressive supranuclear palsy with walleyed bilateral. In this syndrome, the eye on the same side as the damaged medial longitudinal fasciculus is unable to look outward that is, the left eye cannot look left.
This is the first reported anatomic study of a case of posterior internuclear ophthalmoplegia. Pdf a case with internuclear ophthalmoplegia and intermittent. Bilateral internuclear ophthalmoplegia in multiple sclerosis list of authors. To describe the clinical features, mri findings, and pathogenesis of strokes producing internuclear ophthalmoplegia ino as an isolated or predominant clinical manifestation. Internuclear ophthalmoplegia radiology reference article. Internuclear, ophthalmoplegia, mlf, syndrome, medial longitudinal fasciculus, lesions of mlf, ino, neurology, anatomy, phys. See also overview of neuroophthalmologic and cranial nerve disorders. Internuclear definition of internuclear by the free dictionary. This disorder occurs because the brain is sending and receiving faulty information through the nerves that control eye movement. An unusual aetiology for internuclear ophthalmoplegia bmj. He subsequently developed progressive neurological deficit including bilateral internuclear ophthalmoplegia ino, as well as third cranial nerve involvement despite above treatment. Pdf walleyed bilateral internuclear ophthalmoplegia. Rapd, relative afferent pupillary defect, marcusgunn pupil duration.
Prognosis of ischemic internuclear ophthalmoplegia request pdf. This primarily affects conjugate horizontal gaze and classically manifests as impaired adduction ipsilateral to the lesion and abduction nystagmus contralateral to the lesion. People who have this problem may have progressive supranuclear palsy, a disorder that affects the way the brain controls movement. Patients and methods from a clinical registry of a neuroophthalmological department, patients with diagnosis of ino were retrospectively identified. Internuclear ophthalmoplegia ino is a rare eye movement disorder in the pediatric population.
At presentation he displayed impaired adduction of the right eye with normal movement of the left. In internuclear ophthalmoplegia, the nerve fibers that coordinate both eyes in horizontal movementslooking from side to sideare damaged. Background and purpose complete ophthalmoplegia, the combination of bilateral ptosis with loss of all extraocular movements, is rarely a consequence of ischemic stroke. A 40yearold man presented to the emergency room complaining of acute onset blurry vision through his left eye os. A 16yearold girl presented with fluctuating diplopia, ptosis of the left eye and an internuclear ophthalmoplegia ino. Internuclear ophthalmoplegia ino is the inability to move both your eyes together when looking to the side. Internuclear definition of internuclear by the free. Walleyed bilateral ino is the other member of this group of eye movement disorders. Pseudointernuclear ophthalmoplegia as a presenting feature of.
Typical causes of internuclear ophthalmoplegia ino include arterial infarcts, demyelinating conditions, inflammation and trauma. Walleyed bilateral internuclear ophthalmoplegia webino is an uncommon disorder of ocular motility that possesses a unique spectrum of clinical findings, consisting of primary gaze exotropia. When an attempt is made to gaze contralaterally relative to the affected eye, the affected eye adducts minimally, if at all. Complete bilateral horizontal internuclear ophthalmoplegia as a. Internuclear ophthalmoplegia ino is a condition that affects the conjugate lateral gaze, resulting in problems in eye adduction.
If a lesion in the mlf blocks signals from the horizontal gaze. Your right eye manifests jerking movements when you try to look left. Internuclear ophthalmoplegia an overview sciencedirect topics. Internuclear ophthalmoplegia was unilateral in 6 of the infarct cases 87%, 38 of those with multiple sclerosis 27%, and 48 of the unusual cases 42%. Internuclear ophthalmoplegia ino is a common occurrence in ms and it is reported to be present in up to 30% of ms patients 29. Brs neuroanatomy pdf 6th edition is a concise evaluation of medical human neuroanatomy for course and licensing exams, together with the usmle, and options greater than 600 boardstyle evaluation questions with explanations. June 8, 2017 initial presentation chief complaint vision in my left eye is blurry and i am seeing double history of present illness. Internuclear ophthalmoplegia ino describes a clinical syndrome of impaired adduction in one eye with dissociated horizontal nystagmus of the other abducting eye, due to a lesion in the medial longitudinal fasciculus mlf ipsilateral to the eye unable to adduct. Internuclear ophthalmoplegia ino is a sign of exquisite localizing value, often due to either multiple sclerosis or infarction. Internuclear ophthalmoplegia brain, spinal cord, and nerve. This version additionally consists of new fullcolor art work and design components, up to date medical correlations, a glossary of over 200 key phrases, and. Internuclear ophthalmoparesis ino, also commonly referred to as internuclear ophthalmoplegia, is a specific gaze abnormality characterized by impaired horizontal eye movements with weak and slow adduction of the affected eye, and abduction nystagmus of the contralateral eye. Christopher kirkpatrick, md internuclear ophthalmoplegia ino is caused by disruption of the medial longitudinal fasciculus mlf which is a nerve fiber bundle that connects the sixth cranial nerve cn vi nucleus on one side of the pons to the medial rectus subnucleus of the third cranial nerve cn iii in the contralateral midbrain. Bilateral internuclear ophthalmoplegia and third nerve.
The patient developed a transient conjugate gaze palsy and facial palsy with crossed hemiplegia. May, 2012 horners syndrome and internuclear ophthalmoplegia 1. Internuclear ophthalmoplegia is characterized by paresis of ipsilateral eye adduction in horizontal gaze but not in convergence. The condition involves the impairment of horizontal eye gaze due to disruptions in the connection between cranial nerve centers within the brain. In this condition, nerve fibers in the brainstem are damaged hence your left eye cannot look left. Internuclear ophthalmoplegia neurologic disorders msd. Find powerpoint presentations and slides using the power of, find free presentations research about internuclear ophthalmoplegia ppt. These findings led to the diagnosis of ocular myasthenia. Internuclear ophthalmoplegia is a wellrecognized disorder of horizontal eye movements, characterized by impairment of adduction holmes, 192i and. Supranuclear ophthalmoplegia description, causes and risk factors. Internuclear ophthalmoplegia in multiple sclerosis is caused by damage to a bundle of fibers in the brainstem called the medial longitudinal fasciculus. Pula, in aminoffs neurology and general medicine fifth edition, 2014.
The alternating facial hemiplegia persisted, but the. It is one of the most localizing brainstem syndromes, resulting from. Horners syndrome in a case of cvjunction anomaly 26 year malehinduright handed ro bandrastreet hawker, head load worker presented with complaints of progressive weakness in right upper limb since 5 years starting. Few case reports have described bilateral internuclear ophthalmoplegia which is syndrome involving the medial longitudinal fasciculus of the brainstem. Supranuclear ophthalmoplegia medigoo health medical. The contralateral eye abducts, however with nystagmus. Request pdf prognosis of ischemic internuclear ophthalmoplegia to determine the prognosis of internuclear ophthalmoplegia ino caused by infarction.
View and download powerpoint presentations on internuclear ophthalmoplegia ppt. Internuclear ophthalmoplegia ino is a disorder of horizontal ocular movement due to a lesion in the brain stem usually. Jan 26, 2018 internuclear ophthalmoplegia is a condition which affects nerves and limits eye movement. Internuclear ophthalmoplegia as an isolated or predominant. Bilateral internuclear ophthalmoplegia in multiple sclerosis. Cortical input for horizontal eye movement reaches the sixth nerve nucleus via the paramedian pontine reticular formation.
Internuclear ophthalmoplegia british journal of ophthalmology. Brs neuroanatomy pdf 6th edition download free medical. Jun 05, 2017 rapd, relative afferent pupillary defect, marcusgunn pupil duration. Left internuclear ophthalmoplegia was diagnosed, and a full neurological workup was undertaken. Internuclear ophthalmoplegia definition of internuclear. Neurological examination revealed total horizontal ophthalmoplegia lack of saccades and gaze following. Ophthalmoplegia definition of ophthalmoplegia by medical.
Internuclear ophthalmoplegia ino is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. We here report the unique case of a 33yearold man with ino of the right eye caused by infarction of the right midbrain, confirmed by diffusionweighted mri. Ophthalmoplegia definition ophthalmoplegia is a paralysis or weakness of one or more of the muscles that control eye movement. The alternating facial hemiplegia persisted, but the conjugate gaze palsy rapidly resolved into a lateral.
Botulinum toxin in the management of internuclear ophthalmoplegia. Internuclear ophthalmoplegia ino is a disorder of horizontal ocular movement due to a lesion in. During horizontal gaze, the medial longitudinal fasciculus mlf on each side of the brain stem enables. Because unusual causes compose more than one quarter of the cases, the differential diagnosis of ino should be tripartite. Internuclear ophthalmoplegia is related to dysfunction of the medial longitudinal fasciculus, serving to connect the abducens nucleus to the contralateral oculomotor nucleus, coordinating binocular horizontal eye movements. An internuclear ophthalmoplegia ino is an ocular motility disorder due to a lesion involving the medial longitudinal fasciculus mlf. It may be myopathic, meaning that the muscles controlling eye movement are directly involved, or neurogenic, meaning that the nerve pathways controlling eye. Dec 22, 2017 internuclear ophthalmoplegia ino is the inability to move both your eyes together when looking to the side. Arterial infarcts and central nervous system demyelinating conditions like multiple sclerosis are relatively common events, and are the most frequently identified underlying aetiologies in internuclear ophthalmoplegia ino. Internuclear ophthalmoplegia ino is a sign with precise localizing value. Horners syndrome and internuclear ophthalmoplegia 1.