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NEUROLOGY 2008;70:e35
© 2008 American Academy of Neurology
Resident and Fellow Section

Teaching NeuroImage: Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) from midbrain infarction

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J. S. Kim, MD, S. -H. Jeong, MD, Y. -M. Oh, MD, Y. Soon Yang, MD and S. Y. Kim, MD

From the Department of Neurology, College of Medicine, Seoul National University Bundang Hospital, Korea.

Address correspondence and reprint requests to Dr. Sang-Yun Kim, Department of Neurology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea neuroksy{at}snu.ac.kr

A 78-year-old man with hypertension and diabetes was referred because of 3 days of diplopia and ophthalmoplegia. Neurologic examination disclosed exotropia of both eyes (wall-eyed) and bilateral internuclear ophthalmoplegia (WEBINO) with impaired convergence (figure, A).1 Vertical saccades and smooth pursuit were also limited, but improved during the oculocephalic maneuver (video). Pupillary and levator function was normal. MRI demonstrated a circumscribed acute infarction in the midline of the mesencephalic tegmentum involving the bilateral medial longitudinal fasciculus (MLF) which are usually supplied by the anteromedial perforators of the posterior cerebral artery (figure, B).2


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  		Figure Photographs of eye motion and T2- and diffusion-weighted MRIs

(A) Photographs of eye motion demonstrate exotropia of the eyes and adduction deficit of either eye on attempted lateral gaze. Vertical eye motions were also impaired. The arrows indicate the directions of attempted gaze. (B) T2- and diffusion-weighted MRIs disclose an acute infarction in the midline of the midbrain tegmentum involving the bilateral medial longitudinal fasciculus.

 

WEBINO should be differentiated from the exotropia (paralytic pontine exotropia) of one-and-a-half syndrome which denotes unilateral horizontal gaze palsy and internuclear ophthalmoplegia and occurs in the pontine lesion involving the paramedian pontine reticular formation and MLF.3 The dissociated abducting nystagmus, impaired convergence, and supranuclear vertical gaze palsy (video) in our patient support a midbrain lesion damaging the bilateral medial longitudinal fasciculus and pretectum.4

Disclosure: The authors report no conflicts of interest.


   REFERENCES
Top.
 REFERENCES
 

  1. McGettrick P, Eustace P. The W.E.B.I.N.O. syndrome. Neuro-ophthalmology 1985;5:109–115.
  2. Tatu L, Moulin T, Bogousslavsky J, Duvernoy H. Arterial territories of human brain: brainstem and cerebellum. Neurology 1996;47:1125–1135.[Abstract/Free Full Text]
  3. Sharpe JA, Rosenberg MA, Hoyt WF, Daroff RB. Paralytic pontine exotropia: a sign of acute unilateral pontine gaze palsy and internuclear ophthalmoplegia. Neurology 1974;24:1076–1081.[Abstract/Free Full Text]
  4. Sharpe JA, Kim JS. Midbrain disorders of vertical gaze: a quantitative re-evaluation. Ann NY Acad Sci 2002;956:143–154.[Medline]




This Article
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