End and review

Question 15 of 183

A 34 year old woman presents with abnormal gaze. On left horizontal gaze, there is
abduction nystagmus of her left eye and her right eye does not move. Her right sided gaze
is normal. What is the most likely diagnosis?

One-and-half syndrome

Parinaud syndrome

Internuclear ophthalmoplegia

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Internuclear Ophthalmoplegia (INO) Open full article

Internuclear refers to communication between CN6 (Pons) nucleus and the contralateral
CN3 (midbrain) nucleus. This communication is by the medial longitudinal fasciculus
(MLF). A lesion of the MLF results in internuclear ophthalmoplegia.

Normal MLF Function

Normally, the MLF cordinates the CN6 and CN3 to permit horizontal gaze
Recall that CN6 innervates the lateral rectus and CN3 innervates the medial rectus.
The 2 muscles which are needed for horizontal gaze
The MLF connects the CN6 nucleus to the contralateral CN3 nucleus
E.G the RIGHT MLF connects the LEFT CN6 nucleus to the RIGHT CN3.
Identifying The Lesion
Lesion of the right MLF. Right MR function is lost and there is abducting nystagmus of the left eye.
Clinical findings in right INO.
 1 The lesion is made apparent on testing horizontal gaze.
2 Unable to adduct the eye that is ipsilateral to the lesion (Ipsilateral CN3 function
lost)
3 Nystagmus on abduction of the contralateral eye (due to dissociation of vision)

I.e for a RIGHT MLF lesion

On attempted left gaze
Unable to adduct right eye
Abducting nystagmus of the left eye
On attempted right gaze
Normal movement

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