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Done by : shimaa hassan

Resident ophthalmology
3rd year
A 50-year-old female
presented with one week history of double
She also reported an on-and-off headache
. The patient was healthy prior to this
problem and she did not have any known
medical illness, history of head trauma or
drug intake.
The patient did not have any previous episodes of
transient neurological symptoms and no family
history of known neurological diseases

her uncorrected visual acuity was 6/9 in each eye.

Pupils were isocoric and normally reactive with no

relative afferent pupillary defect
. Intraocular pressure was normal

The anterior and posterior segment

examinations were normal in both eyes.
Ophthalmic examination revealed horizontal
diplopia during lateral gaze in both eyes. The
patient had an adduction deficit in the right eye
and ataxic abducting nystagmus in the left eye on
left gaze. She also had an adduction deficit in the
left eye and ataxic abducting nystagmus in the
right eye on right gaze The patient was also unable
to converge.

Ocular motility on up gaze, down gaze, and at

primary position was unremarkable
MRI was ordered it revealed :

numerous areas of punctate signal intensity

consistent with demyelinating plaques involving
the pons, mid-brain, and cerebral hemispheres
neuro-ophthalmic findings and MRI plaques
supported a diagnosis of Bilateral Internuclear
Ophthalmoplegia as a Presenting Sign of Multiple
BINO is caused by demyelinating lesions within
the medial longitudinal fasciculus (MLF)

medial longitudinal fasciculus (MLF),

is a tract that contains axons projecting from the
VI nucleus to the medial rectus subnuclei of the
contralateral III nuclear complex

The MLF is highly myelinated to support the

rapid neural transmission necessary for abduction
of one eye and adduction of the
fellow eye to be nearly synchronous.
Even slight impairment of the transmission
speeds through the MLF produces symptoms by
compromising this synchronicity,
causing ocular misalignment during horizontal

Unlike other myelinated tracts in which slight

impairment may produce no overt clinical deficits,
the system for coordinated horizontal saccades is
extremely sensitive to transmission speeds
making INO a frequent manifestation of MS
Despite deficient adduction during horizontal
saccades, the normal function of the
medial rectus in INO can typically be
demonstrated by testing convergence of the eyes
Convergence is mediated by separate inputs to
the medial rectus subnucleus
that are distinct from the inputs arriving via the
When patients with INO are able to converge,
despite the absence of voluntary adduction, a
caudal lesion with the preservation of the medial
rectus subnuclei of the oculomotor nuclear complex
can be assumed, and this, a more common and
recognized phenomenon, is called Cogans posterior
INO. This patient was, however, unable to converge
and this is indicative of a mesencephalic lesion,
which results in Cogans anterior INO, as
convergence is mediated by nuclei in midbrain
BINO is considered pathognomonic for MS because
there is a strong predilection for the demyelinating
lesions of MS to affect the MLf

While BINO is considered pathognomonic for MS

, other etiologies are possible and should be
considered in cases not consistent with a
diagnosis of MS. Common causes of BINO are
multiple sclerosis
Guillain Barr
systemic lupus erythematosis
brainstem encephalitis
Ischemia of brainstem
progressive supranuclear palsy
metabolic acquired
thiamine deficiency
narcotic overdose
phenothiazines phenytoin
,intrathecal methotrexate

pontine glioma
BINO occurs equal y in men and women, and at any
age in MS patients. Patients with BINO have an ocular
prognosis that is as unpredictable as the MS disease

In some cases, BINO may resolve in a matter of days to

weeks, while in others it can become recurrent and
even permanent. The majority of BINO patients have
no symptoms, but for those with double vision

prismatic spectacle correction may be beneficial

Multiple Sclerosis Association

MS is a slowly progressive disease of unknown

etiology. The disease occurs more commonly in
women than men by a ratio of 2:1.32
There are three types of MS: the benign, relapsing-
remitting, and progressive types.

Patients with the benign type have complete or nearly

complete resolution of symptoms
. The majority of patients have the relapsing-
remitting type.
It is characterized by an unpredictable period of
exacerbation and remission of neurological symptoms.
The progressive type occurs
in the later stage of the disease and is
characterized by a gradual development of
neurological problems

Therapeutic management known as disease-

modifying therapies
(DMT) are used during different aspects of
MS. The three main classes of drugs used to treat
MS are: immunosuppressives,
steroids, and interferon
The only medications proven effective for the ocular
manifestations of MS are intravenous
methylprednisone with a tapering course of oral
prednisone, which is used specifically for the
demyelinating optic neuritis
BINO and other neuro-ophthalmic complications are
important clinical findings that may help establish a
diagnosis of MS.

some cases, patients may overlook other neurological

signs, until a visual symptom develops. Therefore, all
health care providers should be aware of the ocular
signs of this disease