Horizontal Gaze Palsy

This 56 year old woman with known adenocarcinoma of the breast presented with the recent onset of horizontal diplopia and deviation of her left eye inwards. Her oncologist referred her for a neuro-ophthalmic evaluation. This 56 year old woman with known adenocarcinoma of the breast presented with the recent onset of horizontal diplopia and deviation of her left eye inwards. Her oncologist referred her for a neuro-ophthalmic evaluation. Neuro-ophthalmological examination: Visual acuity, fields, pupils and fundi normal Ocular Motility: Unilateral horizontal gaze palsy to the left that impaired saccades and pursuit. Esotropia of the left eye Fascicular sixth nerve palsy Horizontal gaze full to the right, gaze evoked nystagmus Normal convergence, right eye induced to cross the midline Horizontal oculocephalic reflexes absent (Doll's head maneuver) Left lower motor neuron facial palsy (Bell's palsy) Neurological Exam: Normal The constellation of ocular motility signs together with a Bell's palsy localized the lesion to the left side of the pons at the level of the abducens nucleus. Differential Diagnosis: Pontine hemorrhage Pontine infarction Pontine tumor Brain CT: (Figures 1, 2) Demonstrated a focal pontine hemorrhage into a small brainstem metastasis. Bone Scan: Positive for multiple bone metastases. The patient was followed in the Neurovisual Clinic for several months. As she was one of the first patients to be scanned by computer tomography, she wished to donate her body to enable, at autopsy, a clinicopathological correlation of the brainstem lesion with CT imaging. Unfortunately, her family withheld their permission when she died. This case should be viewed alongside ID167-10, a patient with a unilateral horizontal gaze palsy and a pontine infarct. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/62