A Divergence of Views

The presence of a divergence centre in the brain and an associated divergence palsy remain an area of contention within neuro - ophthalmology. We present the case of a pure divergence palsy in the context of Wernicke's Encephalopathy (WE) with very localised MRI changes.

Poster 103 A Divergence of Views Roisin Buckels1, Nadeem Ali1 1 Moorfields Eye Hospital, London, United Kingdom Introduction: The presence of a divergence centre in the brain and an associated divergence palsy remain an area of contention within neuro - ophthalmology. We present the case of a pure divergence palsy in the context of Wernicke's Encephalopathy (WE) with very localised MRI changes. Description of Case(s): A 19 year old morbidly obese female (BMI 41kg/sqm) presented with a two week history of leg pain, weakness and ataxia which rapidly progressed. She had undergone gastric bypass surgery several months earlier with little bariatric success. When admitted to the neurology ward, Miller-Fisher syndrome was suspected. Whilst on the ward she developed oscillopsia and diplopia. Orthoptic examination revealed fine, rapid gaze-evoked nystagmus and on motility testing ductions were full in both eyes. When testing convergence her visual axes aligned at 8cm from the nose with single vision. She had normal convergent and divergent eye movements between her nose and 8cm. Beyond 8cm she developed a large angle alternating esotropia with diplopia which increased gradually up to a maximum of 60 base out prism dioptres at approximately 8m. Following inpatient investigations, the diagnosis was changed to WE secondary to gastric surgery and vitamin B therapy was commenced. MRI showed focal, symmetrical signal abnormality in the medial thalami, periaqueductal midbrain and ependymal surface of the tegmental pons and upper medulla. She showed minimal recovery in her neurological signs over a year after commencing vitamin replacement therapy. Conclusions, including unique features of the case(s): This patient presented with an unusual oculomotor finding of divergence palsy in the context of Wernicke's Encephalopathy following gastric bypass surgery. Thiamine deficiency can present as a Miller-Fisher picture with ataxia, diplopia and areflexia. We believe this case demonstrates what we would term pure divergence palsy, defined as an increasing esotropia beyond a point of binocularity close to the nose with full ductions of either eye. References: Aasheim. Wernicke Encephalopathy After Bariatric Surgery: A Systematic Review.. Ann Surg, Volume 248, pp. 714-720. 2008. Cogan. Divergence paralysis and paralysis of the near reflex associated with a malnutrition syndrome (presumably Wernicke's polioencephalitis).. American Medical Associaton. Archives of Ophthalmology., Volume 46(4), pp. 436-437. 1951. Harper,Giles, Finlay-Jones. Clinical signs in the Wernicke-Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. Journal of Neurology, Neurosurgery & Psychiatry, Volume 49(4), pp.341-345. 1986. Lepore. Divergence paresis: a nonlocalizing cause of diplopia. Journal of Neuro-Ophthalmology : the official journal of the North American Neuro-Ophthalmology Society, Volume 19(4), pp. 242-245. 1999. Keywords: Neuro-ophth & systyemic disease ( eg. MS, MG, thyroid), Ocular Motility, Adult strabismus with a focus on diplopia, Neuroimaging, Nystagmus Financial Disclosures: The authors had no disclosures. Grant Support: None. 2018 Annual Meeting | 148