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1 Bilateral 6th nerve palsies due to idiopathic intracranial hypertensionThis is a 25-year-old woman who presented with diplopia and blurry vision. On exam, she was found to have papilledema and bilateral 6th nerve palsies. Her opening pressure was >40 cm of water with a normal CSF analysis, and neuroimaging was unremarkable aside from subtle findings that have been asso...Sixth Nerve Palsy; Abnormal Range
2 Bilateral INOs Due to StrokeThis is a 65-year-old man with multiple vascular risk factors who experienced the abrupt onset of diplopia 6 months prior to this video. MRI done within 24 hours of onset was unremarkable. Examination demonstrated subtle bilateral adduction lag with horizontal saccades. There was very mild abducting...Abnormal Saccades; Abnormal Range
3 Bilateral INOs and partial 3rd nerve palsiesThis is a 45-year-old man with progressive ptosis and ophthalmoparesis. 10 years prior to presentation, he experienced diplopia and had a hyperintense lesion involving the medial longitudinal fasciculus (MLF) per report. Over time, he developed bilateral adduction paresis, ptosis and upgaze paresis ...Abnormal Range; Third Subnuclear; INO; Mesencephalon
4 Central (Nuclear) 3rd Nerve PalsiesShown here are two patients with left sided midbrain pathology (hemorrhage and ischemia) which caused damage to the 3rd nucleus. Both of the patients have ipsilateral mydriasis, adduction, supra- and infraduction paresis. Ipsilateral>contralateral ptosis is also present, and localizes to the central...Range of eye movements/motility abnormal; Third nuclear; Upgaze palsy; Downgaze palsy; Mesencephalon; Jerk nystagmus; Rotary nystagmus
5 Chronic progressive external ophthalmoplegia (CPEO) and cerebellar signsThis is a 60-yo-woman who initially presented with imbalance and ophthalmoparesis. Initially, there was mild horizontal gaze limitation with mild gaze-evoked nystagmus and slow saccades, and over the years, gait ataxia and dysarthria (mainly a scanning quality to her speech) developed, and her ophth...Abnormal Saccades, Abnormal Range, Horizontal Gaze Palsy, Gaze Evoked Nystagmus
6 Downbeat nystagmus and convergence spasmThis is a 60-yo-woman with vertical oscillopsia related to her downbeat nystagmus, and diplopia related to an intermittent esotropia. When the esotropia was present, with versions there were bilateral abduction deficits. With ductions and the vestibulo-ocular reflex, it was apparent that the range o...Convergence-abnormal, Range-abnormal, Sixth nerve palsy, Convergence spasm, Cerebellar pathology, Jerk nystagmus, Downbeat nystagmus
7 Eye signs in infantile esotropia - latent nystagmus and inferior oblique overactionThis is a 25-yo-man with a history of amblyopia and intermittent eye crossing. On exam, he had a comitant 25 prism diopter esotropia, and other features of infantile (or congenital) esotropia including: latent nystagmus (right-beating nystagmus with occlusion of the left eye and left-beating nystagm...Jerk Nystagmus, Latent Nystagmus, Abnormal Range, Assessing Abnormal Alignment
8 Eyelid retraction, pseudoabducens and upgaze palsy due to a mesodiencephalic hemorrhageThis is a 70-yo-man who suffered a right midline thalamic/rostral midbrain hemorrhagic stroke causing a pretectal (Parinaud's) syndrome. There was prominent eyelid retraction (Collier's sign), a left pseudo-abducens, and upgaze palsy with convergence retraction nystagmus. There was no light-near dis...OMS Mesenecephalon, Convergence Reaction Nystagmus, Upgaze Palsy, Abnormal Range, Sixth Nerve Palsy, Vertical Gaze Palsy, Eyelid Retraction, OMS Dorsal Midbrain
9 Leukemic leptomeningeal carcinomatosis causing 4th and 6th nerve palsiesThis is a 55-yo-man with CML that recurred as AML. Diagonal diplopia developed, and on examination he was found to have a partial right 6th nerve palsy, in addition to a left hypertropia that increased in right gaze, down gaze, and in left head tilt consistent with a left 4th nerve palsy. There was ...Abnormal Range, Fourth Nerve Palsy, Sixth Nerve Palsy
10 Mild 6th Nerve Palsy Due to Pontine StrokeThis is a 70-year-old woman with HTN and diabetes who presented with horizontal diplopia for several weeks, worse in right gaze. There was a very subtle abduction paresis OD with full motility elsewhere. With cover-uncover testing, there was a small esotropia in right gaze (esodeviation seen with al...Abnormal Alignment; Abnormal Range; Sixth Nerve Palsy
11 Miller Fisher Syndrome - Ophthalmoplegia and HyperreflexiaThis is a 45-yo-woman who presented with mild imbalance and diplopia. There had been a preceding viral illness several weeks prior. Examination demonstrated horizontal gaze paresis (sparing unilateral adduction), mild gait ataxia (no clear appendicular ataxia), and hyperreflexia. Pupils were sluggis...Range of eye movements/motility abnormal; Horizontal gaze palsy; Miller Fisher Syndrome
12 Miller Fisher Syndrome - Ophthalmoplegia, Ptosis and AtaxiaThis is a young man who presented with ptosis, difficulty moving the eyes and gait imbalance several weeks after a GI illness. Miller Fisher syndrome was diagnosed, IVIG therapy was initiated, and anti-Gq1b antibodies came back extremely elevated. In addition to ophthalmoplegia, and ataxia, hyporefl...Range of eye movements/motility abnormal; Miller Fisher Syndrome
13 Ocular Motor Signs in Brainstem Demyelinating Disease - Spontaneous Upbeat, Vertical Gaze-Evoked Nystagmus, Slow Saccades, Bilateral Vestibular Loss, INOsThis is a 25-year-old woman who presented with painful vision loss bilaterally two years prior to this video recording, which was diagnosed as optic neuritis. Months later, she experienced oscillopsia and binocular horizontal diplopia and was subsequently diagnosed with multiple sclerosis. No record...Abnormal Saccades; Abnormal VOR-HIT; Abnormal Range; INO; Upbeat Nystagmus; Abducting Nystagmus; Gaze-Evoked Nystagmus
14 Ocular Motor Signs in Early Progressive Supranuclear PalsyThis is a 64-year old man who experienced imbalance and falls (usually backwards) for the last 6 months. He experienced difficulty navigating stairs and had become a messy eater (thought to be in large part due to his vertical gaze palsy), and had developed hypophonia. Exam demonstrated square wave ...Abnormal Saccades; Abnormal Convergence; Abnormal Pursuit; Abnormal Range; Abnormal VORS; Vertical Gaze Palsy; Downgaze Palsy; OMS Mesencephalon
15 Ocular motor signs in progressive supranuclear palsy (PSP)This is a 65-yo-woman complaining of imbalance and double vision. She had significant convergence insufficiency (and would close her right eye with near viewing), providing an explanation for her diplopia. Convergence insufficiency is very common with parkinsonism. She had bradykinesia and rigidity,...Abnormal Pursuit, Abnormal Range, Upgaze Palsy, Downgaze Palsy, Mesencephalon, Square Wave Jerks
16 Oculopalatal Tremor with Prominent Nystagmus, Bilateral Horizontal Gaze Palsy, and Bilateral Facial PalsiesThis is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facial colliculus) were demonstrated by MRI. Five years after her initial presentation she developed recurrent r...Abnormal Range; Sixth Nerve Palsy; Facial Nerve; Horizontal Gaze Palsy; OMS Pons; Pendular Nystagmus; Oculopalatal
17 Oculopalatal Tremor with Prominent Nystagmus, Bilateral Horizontal Gaze Palsy, and Bilateral Facial Palsies Figure 1Figure 1, MRI T2 sequence demonstrating hyperintensities involving bilateral inferior olives of the medulla. This is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facia...Abnormal Range; Sixth Nerve Palsy; Facial Nerve; Horizontal Gaze Palsy; OMS Pons; Pendular Nystagmus; Oculopalatal
18 Parinaud's syndrome in a man with GBM of the pineal glandThis is a 60-yo-man who presented with diplopia, headaches, and difficulty looking up, and was found to have a mass involving the pineal gland. Biopsy was diagnostic of a GBM. Major features of Parinaud's (dorsal midbrain) syndrome were present including: upgaze palsy, convergence retraction nystagm...Saccades; Convergence; Range; Dorsal midbrain syndrome; Convergence retraction nystagmus; Upgaze palsy
19 Parinaud's syndrome with impaired upward saccades and otherwise normal vertical eye movementsThis is a 50-yo-man who suffered a dorsal midbrain stroke. Exam demonstrated normal vertical range of eye movements, normal vertical VOR and smooth pursuit, but inability to perform upward saccades. Another feature of Parinaud's syndrome seen on his exam was light-near dissociation (not shown in thi...abnormal saccades, range of eye movements, abnormal range of eye movements, smooth pursuit, normal VOR, Dorsal midbrain syndrome
20 Pontine hemorrhage causing oculopalatal tremor and multiple cranial neuropathiesThis is a 45-yo-woman who had a dorsal pontine cavernoma that bled 2 years prior to this video. Symptoms included diplopia and oscillopsia. On examination, she had left>right facial palsies (upper and lower face from involvement of the nucleus/fascicle - i.e., lower motor neuron palsies) and sixth n...Sixth Nerve Palsy; Pons; Pendular Nystagmus; Oculopalatal Tremor
21 Range of Eye Movements and Evaluation for NystagmusRange: Assesses for motility deficit due to an ocular motor palsy, particularly if a posterior fossa localization is being considered; Nystagmus: Spontaneous nystagmus may or may not be noted and gaze-evoked nystagmus is common with posterior fossa lesions; nystagmus that is unidirectional in all di...Exam, Nystagmus, Range of Eye Movements
22 Test Your Knowledge - Vertical Saccadic Palsy Due to Bilateral riMLF InfarctionsThis is a 30-year-old who was found minimally responsive on the lounge floor of an ice skating rink. He was brought to the ED, where he had a GCS score of 8 (where 15 is normal) for poor responsiveness. His ocular motor exam is shown in the video. Regarding Finding #1, which of the following is fals...Abnormal Saccades; Normal Optokinetic; Abnormal Range; Vertical Gaze Palsy; Upgaze Palsy; Downgaze Palsy; Mesencephalon; Ocular Motor
23 Typical features of Duane syndrome type 1This is a patient seen for vestibular complaints, who on exam, was found to have (unrelated to her vestibular symptoms) impaired abduction OS. In adduction, there was narrowing of the palpebral fissure OS, a result of globe retraction due to co-contraction of the medial and lateral rectus muscles. T...Abnormal Range, Duane Syndrome, Sixth Nerve Palsy
24 Unilateral 3rd, 4th, and 6th nerve palsies due to cavernous sinus meningiomaThis is a 50-year-old woman presenting with a partial 3rd nerve palsy (mild pupil involvement), partial 6th nerve palsy, and no clear incyclotorsion with downgaze, suggestive of additional 4th nerve palsy, all on the left. With compressive lesions involving the 3rd nerve, often aberrant regeneration...Abnormal Range, Third Nerve Palsy, Aberrant Regeneration, Fourth Nerve Palsy, Sixth Nerve Palsy, Jerk Nystagmus, Downbeat Nystagmus, Gaze Evoked Nystagmus, Abnormal Saccades
25 Vertical gaze palsy and saccadic intrusions due to anti-Ri from head and neck carcinomaA 55-yo- woman was admitted for imbalance and double vision. Three weeks prior to presentation she first noticed swelling on the right side of her face and neck. CT of the head and neck showed right-sided cervical adenopathy and enlarged left retropharyngeal node. Ultrasound- guided biopsy of the n...OMS Mesencephalon, Square Wave Jerks, Upgaze Palsy, Downgaze Palsy, Abnormal Range, Skew, Vertical Gaze Palsy
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