Daniel R. Gold, DO, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, The Johns Hopkins School of Medicine
This is a man who suffered right>left midbrain strokes due to endocarditis complaining of ptosis and inability to move his eyes as well as hallucinations (peduncular hallucinosis). There was a presumed nuclear 3rd nerve palsy on the right (i.e., responsible for his mydriatic pupil, absent supra- and infraduction, adduction, complete ptosis OD and incomplete ptosis OS, and probably responsible for at least some of his supraduction paresis OS), with partial 3rd (fascicular) nerve palsy possibly explaining infra- and supraduction paresis, unreactive pupil OS and perhaps incomplete ptosis OS. There was abducting nystagmus OS suggestive of right MLF damage or gaze-evoked nystagmus without adducting nystagmus OD due to his medial rectur palsy. In addition to adduction and vertical deficits attributable to midbrain ischemia, he also had right>left abduction pareses thought to represent pseudoabducens in the absence of pontine ischemia on several MRIs (done weeks apart), and no pontine neurologic signs on his examination. Interestingly, despite his pseudoabducens pareses being due to a presumed "supranuclear" etiology, they could not be overcome by VOR which has previously been reported.
Spencer S. Eccles Health Sciences Library, University of Utah