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Abstract Details

Internuclear Ophthalmoplegia (INO) with Vertical Misalignment: Is it Skew or is it Trochlear Palsy?
Neuro-ophthalmology/Neuro-otology
P9 - Poster Session 9 (12:00 PM-1:00 PM)
5-009
To present a case of INO with vertical misalignment in a patient with multiple sclerosis and to identify pertinent physical examination findings that can help differentiate between skew deviation and central trochlear palsy. 
INO rarely presents with concomitant trochlear palsy and more often presents with skew deviation. However, with lesions in the dorsal midbrain at the level of the inferior colliculus it is possible to involve both the fascicles of the fourth cranial nerve as well as the medial longitudinal fasciculus to cause an ipsilesional INO and ipsilesional fourth nerve palsy. Multiple physical exam findings can distinguish skew deviation from fourth cranial nerve palsy including Bielschowsky's test and a thorough ophthalmoscopic exam. 
Case report from chart review. 
A 45 year old Caucasian male with a 2 week history of diplopia who was initially found to have a left trochlear nerve palsy later presented with a left INO as well. Exam showed a hypertropic and exotropic left eye (hypertropia worse with left head tilt and better with left eye abduction) with the hypertropia remaining unchanged in supine position. T2/FLAIR MRI demonstrated hyperintense lesions at the level of the inferior colliculus on the left and at the ponto-mesencephalic junction, which explained the left central trochlear palsy and left INO respectively. 

1) Vertical misalignment in the presence of INO does not automatically represent skew deviation. It is possible to be due to trochlear palsy. 

2) A single lesion affecting the MLF and trochlear nucleus will present with ipsilateral INO and contralateral trochlear palsy. 

3) Presence of ipsilateral INO and trochlear palsy indicate 2 separate lesions affecting the fascicles of the trochlear nerve as it exists the brainstem and a separate lesion affecting the MLF. 
Authors/Disclosures
Alexander Lewis, DO (University Hospitals Cleveland Medical Center)
PRESENTER 		Dr. Lewis has nothing to disclose.
Junling Dong, MD No disclosure on file
Neel Fotedar, MD (University Hospitals Cleveland Medical Center) Dr. Fotedar has received research support from NINDS.
Alessandro Serra, MD (University Hospitals Cleveland Medical Center) Dr. Serra has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biogen Idec. Dr. Serra has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Bristol Myers Squibb.
Michael W. Devereaux, MD, FÂ鶹´«Ã½Ó³»­ (Univ Hospitals of Cleveland) Dr. Devereaux has received personal compensation for serving as an employee of DigiTrace part of Sleepmed. Dr. Devereaux has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Kevin Trangle and Associates.