Description
An 84-year-old man with a history of hypertension, diabetes mellitus and ischaemic heart disease, was admitted for sudden onset binocular diplopia and unsteady gait. Physical examination showed primary gaze exotropia of both eyes (figure 1), bilateral internuclear ophthalmoplaegia and impaired vertical gaze of his right eye (video 1). Convergence, saccades and smooth pursuit were impaired. Vestibulo-ocular reflex was normal. Pupillary and levator function was normal. MRI of the brain revealed a paramedian mesencephalic infarct (figure 2). The patient's condition improved significantly after treatment with aspirin and rehabilitation therapy.
Figure 1.
Primary gaze exotropia of both eyes.
Figure 2.
MRI DWI image shows an infarct in paramedian midbrain. DWI, diffusion weighted imaging.
Video 1.
Bilateral internuclear ophthalmoplaegia.
Wall-eyed bilateral internuclear ophthalmoplaegia (WEBINO) is a rare neuro-ophthalmological condition characterised by dissociated abducting nystagmus, impaired convergence and supranuclear vertical gaze palsy.1 2 It is caused by a midbrain lesion damaging the bilateral medial longitudinal fasciculus and pretectum, which is supplied by the anteromedial perforators of the posterior cerebral artery.2
Learning points.
Wall-eyed bilateral internuclear ophthalmoplaegia (WEBINO) is a rare neuro-ophthalmological condition characterised by dissociated abducting nystagmus, impaired convergence and supranuclear vertical gaze palsy.
It is caused by a midbrain lesion damaging the bilateral medial longitudinal fasciculus and pretectum, which is supplied by the anteromedial perforators of the posterior cerebral artery.
Footnotes
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
- 1.McGettrick P, Eustace P. The W.E.B.I.N.O. syndrome. Neuro-ophthalmology 1985;5:109–15. doi:10.3109/01658108509014426 [Google Scholar]
- 2.Kim JS, Jeong SH, Oh YM et al. Teaching NeuroImage: wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) from midbrain infarction. Neurology 2008;70:e35 doi:10.1212/01.wnl.0000299904.48116.cf [DOI] [PubMed] [Google Scholar]