INTERNUCLEAR OPHTHALMOPLEGIA

SIGNS AND SYMPTOMS

Several underlying systemic diseases can cause this condition. There is a painless onset of visual disturbance, but often no diplopia in primary gaze. There will be horizontal diplopia in lateral gaze. The patient will manifest an adduction deficit on the involved side and a nystagmus of the fellow eye in extreme abduction. Occasionally, the condition is bilateral with medial rectus palsy and adduction deficit in each eye and nystagmus upon abduction in both eyes (bilateral internuclear ophthalmoplegia, or BINO) While there appears to be medial recti palsy, most patients will be able to converge (posterior INO or BINO). In some cases, the patient will not be able to converge (anterior INO or BINO).

PATHOPHYSIOLOGY
To produce synchronous eye movements, cranial nerves III, IV and VI communicate through the medial longitudinal fasciculus (MLF), the neural pathway connecting the cranial nerve nuclei responsible for eye movements. In INO, a lesion disrupts this pathway, preventing communication between cranial nerves. For example, for a patient to gaze to the left, the left supranuclear control center of horizontal eye movements [paramedian pontine reticular formation (PPRF)] must signal the left CN VI nucleus to turn the left eye outwards. At the same time, the PPRF must signal the right CN III nucleus, via the right MLF, to simultaneously turn the right eye inwards. A lesion of the right MLF would not allow the neural impulse to reach the right medial rectus. In this case, the left eye would abduct, but the right eye would not adduct. Further, the left eye would go into an abducting nystagmus. Most lesions of the MLF are located in the pons, or caudal mesencephalon. Thus, patients with INO or BINO will be able to converge (posterior INO/BINO). However, if the lesion affects the MLF within the mesencephalon and involves the CN III nucleus, then the patient will not be able to converge (anterior INO/BINO). Possible causes of INO/BINO: multiple sclerosis brainstem infarction brainstem and fourth ventricular tumor viral infection trauma syphilis Lyme disease drug intoxication (phenothiazines and tricyclic antidepressants) subdural hematoma

Typically, multiple sclerosis causes a bilateral presentation, whereas ischemic vascular infarction causes a unilateral episode. Also, myasthenia gravis can produce a pseudo-INO/BINO with a motility pattern identical to true INO/BINO.

MANAGEMENT
Manage INO/BINO by identifying the underlying cause, and then obtaining appropriate medical treatment. In cases of ischemic vascular infarction, the motility pattern returns to normal over time. Appropriate testing includes MRI of the brainstem, FTA-ABS, VDRL, Lyme titre, fasting blood glucose, complete blood count with differential, blood pressure measurement, and toxicology screen.

CLINICAL PEARLS
Remember that myasthenia gravis can mimic the motility pattern of INO/BINO.

In younger patients, the etiology of INO/BINO is most commonly multiple sclerosis. In fact, INO/BINO is the most common ocular motility dysfunction in MS. Approximately 92 percent of patients who develop INO/BINO from demyelinization develop MS. In older patients who develop INO/BINO, the most common etiology is ischemic vascular infarction. Beyond MRI studies, these patients need medical evaluation for ischemic vascular diseases such as diabetes and hypertension. These cases typically resolve over time.

Other reports in this section

Anterior Ischemic Optic Neuropathy Optic Disc Edema & Papilledema Cranial Nerve III Palsy Cranial Nerve IV Palsy Cranial Nerve VI Palsy Cranial Nerve VII (Facial Nerve) Palsy Horner's Syndrome Internuclear Ophthalmoplegia Optic Nerve Head Hypoplasia Optic Pit Tonic Pupil Acquired Glaucomatous Changes of the Optic Nerve Head (Pictorial) Optic Nerve Head Drusen Demyelinating Optic Neuropathy (Optic Neuritis, Retrobulbar Optic Neuritis) Amaurosis Fugax and Transient Ischemic Attack Pseudotumor Cerebri Pituitary Adenoma

Internuclear Ophthalmoplegia

What is internuclear ophthalmoplegia

Internuclear ophthalmoplegia is eye disorder that results from the damage of given nerve connections that link the eye and the brain. It results to impairment of the horizontal movements of the eye. It is a condition where the nerve fibers that control the horizontal movements of the eye fail to work. People suffering from this condition will find it hard to look side to side. These damaged fibers connect many nerve cells. It is a condition that can occur in both old and younger people. For adults, it can be as a result of stroke, and mostly it affects one eye. There are other minor causes such as tumors, Lyme disease, and toxicity as a result of use of drugs like antidepressants.

Symptoms of internuclear ophthalmoplegia

People suffering from internuclear ophthalmoplegia will have the horizontal eye movements of their eye impaired, but vertical movements will remain unaffected. The affected eye will prove difficult to turn it inwards. It will rather insist on turning outwards. When the affected person tries to focus to the opposite side of the eye with the problem, the eye will prove hard to turn to a given angle. It will focus straight ahead. This is what makes it difficult for the patient to see what is happening on the side.

Internuclear Ophthalmoplegia

When the patient tries to turn the affected eye outwards, it will make rapid movements in one direction. It will then slowly drift the other direction. Patients of internuclear ophthalmoplegia will experience double vision. When the patient tries to look sideways, the affected eye will remain motionless in the middle. The other eye will only turn outward but fail to turn inwards.

Internuclear ophthalmoplegia and blindness

In internuclear ophthalmoplegia, the eyes can turn inward when the person looks inward even though it fails to turn inwards when look to the sides. The treatment of this disorder will depend on what caused it. This disorder can result from weakening of the particular muscles of the eye. The partner eye will tend to diverge from affected eye. The coordination between the two will no longer be there. This is what will result to double vision i.e. the affected patient will see double when looking sideways. The images will be side by side. If this condition is extreme, it can lead to blurred vision. With research being done on this condition, scientists have proved that left-sided internuclear ophthalmoplegia is the same as the right-sided internuclear ophthalmoplegia. Both will be characterized by the impairment of the horizontal eye movement while the vertical movements remain intact. Among the causes of this condition is head trauma especially a severe one. The most common cause is falls and blunt trauma. Damages to the brain can also result to this condition. Neoplasms in children like pontine gliomas and medulloblastomas can result to this disease. If you are affected by this condition, it is good to consult a doctor and get a solution for the same. If treated well in advance, this condition can be dealt with completely once and for all.