Bilateral ptosis with wall-eyed bilateral internuclear ophthalmoplegia and vertical gaze paralysis

Excerpt

A 53-year-old patient presented in the neurological emergency department complaining of sudden onset of blurry vision, as well as difficulty opening his eyes. He had no previous medical history, and of significance was his body mass index of 48. Initial neurological examination showed binocular vertical double vision, bilateral ptosis with exotropia of the left eye, bilateral adduction deficit combined with abducting nystagmus (wall-eyed bilateral internuclear ophthalmoplegia, WEBINO) and vertical gaze paralysis. Bedside examination showed normal acuity and no visual field deficit. During the examination, patient quickly deteriorated, becoming comatose, tetraplegic, with unreactive pupils, anisocoria (right pupil wider) and ataxic breathing. After lowering his blood pressure from 260/160 to 160/90 mmHg, his condition improved to somnolence, dysarthria, bilateral ptosis, anisocoria with medium sized fixed pupils (R > L), bilateral adduction deficit with abducting nystagmus and exotropia (more pronounced on the left eye), skew deviation (hypertropia of the left eye, presence of incyclotorsion was uncertain in the setting of bedside examination in emergency department) and vertical gaze paralysis (Fig. 1, Video 1). There was no compensating head tilt and no ocular counter-roll, while vertical VOR were absent.

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